Shapiro Susan P
American Bar Foundation.
J Health Polit Policy Law. 2015 Jun;40(3):487-530. doi: 10.1215/03616878-2888424. Epub 2015 Feb 19.
Resolution of long-standing debates about the role and impact of advance directives - living wills and powers of attorney for health care - has been hampered by a dearth of appropriate data, in particular data that compare the process and outcomes of end-of-life decision making on behalf of patients with and without advance directives. Drawing on a large ethnographic study of patients in two intensive care units in a large urban teaching hospital, this article compares aspects of the medical decision-making process and outcomes by advance-directive status. Controlling for demographic characteristics and severity of illness, the study finds few significant differences between patients without advance directives and those who claim to have them. Surprisingly, these few differences hold only for those whose directives are in their hospital chart. There are no significant differences between those with no directive and those claiming to have a copy at home or elsewhere. The article considers the implications if directives seemingly must be in hand to show even modest effects. Do advance directives direct? The intensive care unit data provide far more support for the growing body of literature that casts doubt on their impact than studies that promote the use of them.
关于预先指示（生前遗嘱和医疗保健委托书）的作用和影响的长期争论，因缺乏适当数据而受阻，尤其是缺乏对有和没有预先指示的患者进行临终决策过程和结果比较的数据。本文借鉴了对一家大型城市教学医院两个重症监护病房患者进行的大型人种学研究，按预先指示状态比较了医疗决策过程和结果的各个方面。在控制人口统计学特征和疾病严重程度后，研究发现没有预先指示的患者与声称有预先指示的患者之间几乎没有显著差异。令人惊讶的是，这为数不多的差异仅适用于那些指示在其医院病历中的患者。没有指示的患者与声称在家中或其他地方有副本的患者之间没有显著差异。本文考虑了如果指示似乎必须在手才能显示出哪怕是适度的效果会有什么影响。预先指示能起到指导作用吗？重症监护病房的数据为越来越多质疑其影响的文献提供了更多支持，而不是那些提倡使用预先指示的研究。
