Sudore Rebecca L, Casarett David, Smith Dawn, Richardson Diane M, Ersek Mary
San Francisco VA Medical Center, University of California, San Francisco, California, USA; Division of Geriatrics, University of California, San Francisco, California, USA.
University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.
J Pain Symptom Manage. 2014 Dec;48(6):1108-16. doi: 10.1016/j.jpainsymman.2014.04.001. Epub 2014 May 2.
Most patients will lose decision-making capacity at the end of life. Little is known about the quality of care received by patients who have family involved in their care.
To evaluate differences in the receipt of quality end-of-life care for patients who died with and without family involvement.
We retrospectively reviewed the charts of 34,290 decedents from 146 acute and long-term care Veterans Affairs facilities between 2010 and 2011. Outcomes included: (1) palliative care consult, (2) chaplain visit, and 3) death in an inpatient hospice or palliative care unit. We also assessed "do not resuscitate" (DNR) orders. Family involvement was defined as documented discussions with the health care team in the last month of life. We used logistic regression adjusted for demographics, comorbidity, and clustered by facility. For chaplain visit, hospice or palliative care unit death, and DNR, we additionally adjusted for palliative care consults.
Mean (SD) age was 74 (±12) years, 98% were men, and 19% were nonwhite. Most decedents (94.2%) had involved family. Veterans with involved family were more likely to have had a palliative care consult, adjusted odds ratio (AOR) 4.31 (95% CI 3.90-4.76); a chaplain visit, AOR 1.18 (95% CI 1.07-1.31); and a DNR order, AOR 4.59 (95% CI 4.08-5.16) but not more likely to die in a hospice or palliative care unit.
Family involvement at the end of life is associated with receipt of palliative care consultation and a chaplain visit and a higher likelihood of a DNR order. Clinicians should support early advance care planning for vulnerable patients who may lack family or friends.
大多数患者在生命末期会丧失决策能力。对于有家人参与护理的患者所接受的护理质量，我们了解甚少。
评估在有或没有家人参与护理的情况下死亡的患者在接受优质临终护理方面的差异。
我们回顾性审查了2010年至2011年间146家急性和长期护理退伍军人事务机构中34290名死者的病历。结果包括：（1）姑息治疗咨询；（2）牧师探访；以及（3）在住院临终关怀或姑息治疗病房死亡。我们还评估了“不要复苏”（DNR）医嘱。家人参与被定义为在生命的最后一个月与医疗团队进行的有记录的讨论。我们使用了经人口统计学、合并症调整并按机构聚类的逻辑回归分析。对于牧师探访、临终关怀或姑息治疗病房死亡以及DNR医嘱，我们还对姑息治疗咨询进行了调整。
平均（标准差）年龄为74（±12）岁，98%为男性，19%为非白人。大多数死者（94.2%）有家人参与护理。有家人参与护理的退伍军人更有可能接受姑息治疗咨询，调整后的优势比（AOR）为4.31（95%置信区间3.90 - 4.76）；接受牧师探访，AOR为1.18（95%置信区间1.07 - 1.31）；以及有DNR医嘱，AOR为4.59（95%置信区间4.08 - 5.16），但在临终关怀或姑息治疗病房死亡的可能性并不更高。
生命末期家人的参与与接受姑息治疗咨询、牧师探访以及下达DNR医嘱的可能性更高相关。临床医生应为可能缺乏家人或朋友的弱势患者提供早期的预立医疗计划支持。
