Danis M, Southerland L I, Garrett J M, Smith J L, Hielema F, Pickard C G, Egner D M, Patrick D L
Department of Medicine, University of North Carolina, Chapel Hill 27599-7110.
N Engl J Med. 1991 Mar 28;324(13):882-8. doi: 10.1056/NEJM199103283241304.
The use of advance directives is recommended so that people can determine the medical care they will receive when they are no longer competent, but the effectiveness of such directives is not clear.
In a prospective study conducted over a two-year period, 126 competent residents of a nursing home and 49 family members of incompetent patients were interviewed to determine their preferences with respect to hospitalization, intensive care, cardiopulmonary resuscitation, artificial ventilation, surgery, and tube feeding in the event of critical illness, terminal illness, or permanent unconsciousness. Advance directives, consisting of signed statements of treatment preferences, were placed in the medical record to assist in care in the nursing home and to be forwarded to the hospital if necessary.
In an analysis of 96 outcome events (hospitalization or death in the nursing home), care was consistent with previously expressed wishes 75 percent of the time; however, the presence of the written advance directive in the medical record did not facilitate consistency. Among the 24 events in which inconsistencies occurred, care was provided more aggressively than had been requested in 6 cases, largely because of unanticipated surgery or artificial ventilation, and less aggressively than requested in 18, largely because hospitalization or cardiopulmonary resuscitation was withheld. Inconsistencies were more likely in the nursing home than in the hospital. CONCLUSIONS. The effectiveness of written advance directives is limited by inattention to them and by decisions to place priority on considerations other than the patient's autonomy. Since our study was performed in only one nursing home and one hospital, other studies are necessary to determine the generalizability of our findings.
建议使用预先指示，以便人们在失去行为能力时能够确定自己将接受的医疗护理，但此类指示的有效性尚不清楚。
在一项为期两年的前瞻性研究中，对126名养老院中有行为能力的居民和49名无行为能力患者的家庭成员进行了访谈，以确定他们在患重病、绝症或永久昏迷时对住院、重症监护、心肺复苏、人工通气、手术和管饲的偏好。预先指示由签署的治疗偏好声明组成，被放入病历中，以协助养老院的护理，并在必要时转发给医院。
在对96例结局事件（养老院住院或死亡）的分析中，75%的情况下护理与先前表达的意愿一致；然而，病历中存在书面预先指示并未促进一致性。在发生不一致的24例事件中，6例提供的护理比要求的更为积极，主要是因为意外手术或人工通气，18例则比要求的更为消极，主要是因为未进行住院治疗或心肺复苏。养老院中的不一致情况比医院中更常见。结论。书面预先指示的有效性受到对其关注不足以及将优先级置于患者自主权以外的考虑因素的决定的限制。由于我们的研究仅在一家养老院和一家医院进行，因此需要其他研究来确定我们研究结果的普遍性。
