Univ Dusseldorf, Medical Faculty, Department of General Practice, D-40225 Dusseldorf, Germany.
BMC Health Serv Res. 2011 Jan 24;11:14. doi: 10.1186/1472-6963-11-14.
Advance Care Planning (ACP) is an emerging strategy to ensure that well-reflected, meaningful and clearly documented treatment preferences are available and respected when critical decisions about life-sustaining treatment need to be made for patients unable to consent. In Germany, recent legislation confirms that advance directives (AD) have to be followed if they apply to the medical situation, but implementation of ACP has not yet been described.
METHODS/DESIGN: In a longitudinal controlled study, we compare 1 intervention region (4 nursing homes [n/hs], altogether 421 residents) with 2 control regions (10 n/hs, altogether 985 residents). Inclusion went from 01.02.09 to 30.06.09, observation lasted until 30.06.10. Primary endpoint is the prevalence of ADs at follow-up, 17 (12) months after the first (last) possible inclusion. Secondary endpoints compare relevance and validity of ADs, process quality, the rate of life-sustaining interventions and, in deceased residents, location of death and intensity of treatment before death. The regional multifaceted intervention on the basis of the US program Respecting Choices® comprises training of n/h staff as facilitators, training of General Practitioners, education of hospital and ambulance staff, and development of eligible tools, including Physician Orders for Life-Sustaining Treatment in case of Emergency (POLST-E). Participation data: Of 1406 residents reported to live in the 14 n/hs plus an estimated turnover of 176 residents until the last possible inclusion date, 645 (41%) were willing to participate. Response rates were 38% in the intervention region and 42% in the control region. Non-responder analysis shows an equal distribution of sex and age but a bias towards dependency on nursing care in the responder group. Outcome analysis of this study will become available in the course of 2011.
Implementing an ACP program for the n/hs and related health care providers of a region requires a complex community intervention with the effect of nothing less than a cultural shift in this health care sector. This study is to our knowledge the first to develop a strategy for regional implementation of ACP, and to evaluate its feasibility in a controlled design.
预先医疗指示（Advance Care Planning，ACP）是一种新兴策略，旨在确保当患者无法做出同意决定时，能够获得并尊重那些经过深思熟虑、有意义且明确记录的治疗偏好。在德国，最近的立法规定，如果预先医疗指示（Advance Directives，AD）适用于医疗情况，则必须遵循，但尚未描述 ACP 的实施情况。
方法/设计：在一项纵向对照研究中，我们比较了一个干预区域（4 家养老院[护理院]，共 421 名居民）和两个对照区域（10 家护理院，共 985 名居民）。纳入时间从 2009 年 2 月 1 日至 6 月 30 日，观察持续到 2010 年 6 月 30 日。主要终点是随访时预先医疗指示的流行率，即第一次（最后一次）可能纳入后 17（12）个月。次要终点比较预先医疗指示的相关性和有效性、过程质量、维持生命的干预措施率以及死亡居民的死亡地点和死亡前治疗强度。基于美国项目“尊重选择”（Respecting Choices®）的区域多方面干预措施包括对护理院工作人员进行培训，使其成为促进者，培训全科医生，教育医院和救护车工作人员，并开发合格工具，包括在紧急情况下的《医生生命维持治疗医嘱》（POLST-E）。参与数据：在报告居住在 14 家护理院加估计到最后一次可能纳入日期为止的 176 名居民的 1406 名居民中，645 名（41%）愿意参与。干预组的回应率为 38%，对照组为 42%。非回应者分析显示，在回应者组中，性别和年龄分布均衡，但对护理依赖存在偏见。这项研究的结果分析将在 2011 年进行。
为护理院和相关卫生保健提供者实施 ACP 计划需要一项复杂的社区干预，其效果不亚于该卫生保健部门的文化转变。这项研究是我们所知的第一个为区域实施 ACP 制定策略的研究，并以对照设计评估其可行性。
