Division of General Internal Medicine, Carver College of Medicine, University of Iowa, 200 Hawkins Dr., C44-N GH, Iowa City, IA 52242, USA.
Psychiatr Serv. 2011 Jan;62(1):61-6. doi: 10.1176/ps.62.1.pss6201_0061.
Nursing home residents with serious mental illness need a high level of general medical and end-of-life services. This study tested whether persons with serious mental illness are as likely as other nursing home residents to make informed choices about treatments through medical advance care plans.
Secondary analyses were conducted with data from a 2004 national survey of nursing home residents with (N=1,769) and without (N=11,738) serious mental illness. Bivariate and multivariate analyses determined differences in documented advance care plans, including living wills; do-not-resuscitate and do-not-hospitalize orders; and orders concerning restriction of feeding tube, medication, or other treatments.
The overall rates of having any of the four advance care plans were 57% and 68% for residents with and without serious mental illness, respectively (p<.001). Residents with serious mental illness also showed lower rates for individual advance care plans. In a multivariate analysis that adjusted for resident and facility characteristics (N=1,174 nursing homes) as well as survey procedures, serious mental illness was associated with a 24% reduced odds of having any advance directives (adjusted odds ratio=.76, 95% confidence interval=.66-.87, p<.001). Similar results were found for individual documented plans.
Among U.S. nursing home residents, those with serious mental illness were less likely than others to have written medical advance directives. Future research is needed to help understand both resident factors (such as inappropriate behaviors, impaired communication skills, and disrupted family support) and provider factors (including training, experience, and attitude) that underlie this finding.
患有严重精神疾病的养老院居民需要高水平的一般医疗和临终服务。本研究检验了严重精神疾病患者是否像其他养老院居民一样，能够通过医疗预先护理计划做出明智的治疗选择。
利用 2004 年对养老院居民（患有严重精神疾病者 N=1769 人，无严重精神疾病者 N=11738 人）进行的全国性调查数据进行二次分析。对有记录的预先护理计划（包括生前遗嘱、不复苏和不入院命令，以及限制喂养管、药物或其他治疗的命令）进行了单变量和多变量分析。
患有严重精神疾病和无严重精神疾病的居民分别有 57%和 68%（p<.001）制定了上述四项预先护理计划中的任意一项。患有严重精神疾病的居民在个人预先护理计划中的比例也较低。在一项调整了居民和设施特征（N=1174 家养老院）以及调查程序的多变量分析中，患有严重精神疾病与制定任何预先指示的可能性降低 24%有关（调整后的优势比=.76，95%置信区间.66-.87，p<.001）。对于有记录的个别计划也得出了类似的结果。
在美国养老院居民中，患有严重精神疾病的居民制定书面医疗预先指示的可能性低于其他居民。需要进一步研究，以帮助理解导致这一发现的居民因素（如不当行为、沟通能力受损和家庭支持中断）和提供者因素（包括培训、经验和态度）。
