一项旨在改善 COPD 患者临终关怀沟通的随机试验。
A randomized trial to improve communication about end-of-life care among patients with COPD.
机构信息
Health Services Research and Development, VA Puget Sound Health Care System, University of Washington, Seattle, WA; Department of Medicine, University of Washington, Seattle, WA.
Health Services Research and Development, VA Puget Sound Health Care System, University of Washington, Seattle, WA.
出版信息
Chest. 2012 Mar;141(3):726-735. doi: 10.1378/chest.11-0362. Epub 2011 Sep 22.
OBJECTIVE
Patients with COPD consistently express a desire to discuss end-of-life care with clinicians, but these discussions rarely occur. We assessed whether an intervention using patient-specific feedback about preferences for discussing end-of-life care would improve the occurrence and quality of communication between patients with COPD and their clinicians.
METHODS
We performed a cluster-randomized trial of clinicians and patients from the outpatient clinics at the Veterans Affairs Puget Sound Health Care System. Using self-reported questionnaires, we assessed patients' preferences for communication, life-sustaining therapy, and experiences at the end of life. The intervention clinicians and patients received a one-page patient-specific feedback form, based on questionnaire responses, to stimulate conversations. The control group completed questionnaires but did not receive feedback. Patient-reported occurrence and quality of end-of-life communication (QOC) were assessed within 2 weeks of a targeted visit. Intention-to-treat regression analyses were performed with generalized estimating equations to account for clustering of patients within clinicians.
RESULTS
Ninety-two clinicians contributed 376 patients. Patients in the intervention arm reported nearly a threefold higher rate of discussions about end-of-life care (unadjusted, 30% vs 11%; P < .001). Baseline end-of-life communication was poor (intervention group QOC score, 23.3; 95% CI, 19.9-26.8; control QOC score, 19.2; 95% CI, 15.9-22.4). Patients in the intervention arm reported higher-quality end-of-life communication that was statistically significant, although the overall improvement was small (Cohen effect size, 0.21).
CONCLUSIONS
A one-page patient-specific feedback form about preferences for end-of-life care and communication improved the occurrence and quality of communication from patients' perspectives.
TRIAL REGISTRY
ClinicalTrials.gov; No.: NCT00106080; URL: www.clinicaltrials.gov.
目的
慢性阻塞性肺疾病（COPD）患者一直表示希望与临床医生讨论临终关怀事宜，但这些讨论很少发生。我们评估了使用关于讨论临终关怀偏好的患者特定反馈的干预措施是否会改善 COPD 患者与临床医生之间沟通的发生和质量。
方法
我们对退伍军人事务部普吉特湾医疗保健系统门诊的临床医生和患者进行了一项聚类随机试验。我们使用自我报告的问卷评估了患者对沟通、生命支持治疗和临终体验的偏好。干预组的临床医生和患者收到了一份基于问卷回答的一页患者特定反馈表，以促进对话。对照组完成了问卷，但没有收到反馈。在目标就诊后的两周内，患者报告了临终沟通的发生和质量（QOC）。使用广义估计方程进行意向治疗回归分析，以解释患者在临床医生中的聚类。
结果
92 名临床医生贡献了 376 名患者。干预组患者报告的临终关怀讨论率几乎高出三倍（未经调整，30%比 11%；P <.001）。基线临终沟通质量较差（干预组 QOC 评分 23.3；95%CI，19.9-26.8；对照组 QOC 评分 19.2；95%CI，15.9-22.4）。干预组患者报告的临终沟通质量更高，尽管总体改善较小，但具有统计学意义（Cohen 效应量，0.21）。
结论
一份关于临终关怀和沟通偏好的一页患者特定反馈表提高了患者视角下的沟通发生和质量。
试验注册
ClinicalTrials.gov；编号：NCT00106080；网址：www.clinicaltrials.gov。
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