Rüddel H, Zenz M
Klinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Jena, Erlanger Allee 101, Jena, Germany.
Anaesthesist. 2011 Apr;60(4):325-33. doi: 10.1007/s00101-010-1816-5. Epub 2010 Dec 25.
German Legislation has defined the legal significance of advance directives (AD). Nevertheless, many precast ADs are of limited help in clinical decision making. Empirical results are rare and controversial. The SUPPORT study showed that precast ADs had a tendency to being ignored. Value-based AD proved to be of help in the interpretation of patients' wills by physicians. We therefore investigated whether a value-based AD that can be individualized with the help of a check-box-system is a valid instrument of communicating the patient's preferences. This is the first validation of an AD.
In our study we evaluated the acceptance and practicability of an AD. Questionnaires and the AD itself were handed out to patients, relatives, and members of the nursing and medical staff. All were asked to fill out the AD, mark all unclear passages, make amendments to the AD if wanted and finally were asked to answer a questionnaire regarding the AD. The level of significance was defined at 5%, meaning that every "unwanted" answer exceeding 5% or passages with more than 5% of the total remarks were analyzed and it was checked whether changes to the AD should be made.
The return rate was 64.8% (201 of 310). The results were highly positive for the items "understandable" (81,6%), "clarifying" (65,7%), "helpful" (76,1%), and "sensible" (75,1%). 70% of patients and relatives stated that they were able to express personal wishes and values with this AD, as well as a majority of the medical staff (44% vs. 30%). The discrepancy between the groups was significant (ChiSq=13.11, p<.001). All paragraphs of the check-box-system were validated as understandable and clear in intention. Major concerns were the inability of expressing own wishes and values (by 16,4% of all participants) and the fear of later alterations (15,4%). According to the findings and the evaluations the AD was modified.
The value-based AD which is routinely used in a university hospital and which can be individualized by a check-box-system was broadly accepted by the test subjects and showed highly positive results with respect to the analyzed items. Only minor changes were derived from our study to hopefully raise its acceptance even more. The discrepancy between patients, relatives and the medical staff concerning the possibility to express one's wishes and values was surprising and in contradiction to former findings. However, our study cannot answer whether the higher level of distrust among medical staff can be explained by negative professional experiences.
The investigated AD with a check box system seems to be an adequate instrument to communicate patient's wishes and directives.
德国立法已明确了预先指示（AD）的法律意义。然而，许多预制的预先指示在临床决策中帮助有限。实证结果稀少且存在争议。SUPPORT研究表明预制的预先指示往往被忽视。基于价值观的预先指示被证明有助于医生解读患者的意愿。因此，我们调查了一种借助复选框系统可实现个性化的基于价值观的预先指示是否是传达患者偏好的有效工具。这是对预先指示的首次验证。
在我们的研究中，我们评估了一份预先指示的可接受性和实用性。问卷及预先指示本身被分发给患者、亲属以及护理和医务人员。所有人都被要求填写预先指示，标记所有不清楚的段落，如有需要对预先指示进行修改，最后回答一份关于该预先指示的问卷。显著性水平设定为5%，这意味着每个超过5%的“不理想”答案或占总评论5%以上的段落都要进行分析，并检查是否应对预先指示进行修改。
回收率为64.8%（310份中的201份）。对于“易懂”（81.6%）、“有启发性”（65.7%）、“有帮助”（76.1%）和“合理”（75.1%）这些项目，结果呈高度积极。70%的患者和亲属表示他们能够通过这份预先指示表达个人愿望和价值观，医务人员中的大多数也这样认为（44%对30%）。两组之间的差异具有显著性（卡方 = 13.11，p <.001）。复选框系统的所有段落经验证都易懂且意图清晰。主要担忧是无法表达自己的愿望和价值观（占所有参与者的16.4%）以及担心日后被更改（15.4%）。根据研究结果和评估对预先指示进行了修改。
在大学医院常规使用的、可通过复选框系统实现个性化的基于价值观的预先指示得到了测试对象的广泛接受，并且在分析项目方面显示出高度积极的结果。我们的研究仅产生了一些小的修改，希望能进一步提高其可接受性。患者、亲属和医务人员在表达个人愿望和价值观的可能性方面存在差异，这令人惊讶且与之前的研究结果相矛盾。然而，我们的研究无法回答医务人员中较高的不信任程度是否可由负面的专业经历来解释。
所研究的带有复选框系统的预先指示似乎是传达患者愿望和指示的合适工具。
