Klingler Corinna, in der Schmitten Jürgen, Marckmann Georg
Institute for Ethics, History and Theory of Medicine, Ludwig Maximilian University, Munich, Germany.
Institute of General Practice, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany.
Palliat Med. 2016 May;30(5):423-33. doi: 10.1177/0269216315601346. Epub 2015 Aug 20.
While there is increasing evidence that Advance Care Planning has the potential to strengthen patient autonomy and improve quality of care near the end of life, it remains unclear whether it could also reduce net costs of care.
This study aims to describe the cost implications of Advance Care Planning programmes and discusses ethical conflicts arising in this context.
We conducted a systematic review based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement.
We systematically searched the databases PubMed, NHS EED, EURONHEED, Cochrane Library and EconLit. We included empirical studies (no limitation to study type) that investigated the cost implications of Advance Care Planning programmes involving professionally facilitated end-of-life discussions.
Seven studies met our inclusion criteria. Four of them used a randomised controlled design, one used a before-after design and two were observational studies. Six studies found reductions in costs of care ranging from USD1041 to USD64,827 per patient, depending on the study period and the cost measurement. One study detected no differences in costs. Studies varied considerably regarding the Advance Care Planning intervention, patient selection and costs measured which may explain some of the variations in findings.
Looking at the impact of Advance Care Planning on costs raises delicate ethical issues. Given the increasing pressure to reduce expenditures, there may be concerns that cost considerations could unduly influence the sensitive communication process, thus jeopardising patient autonomy. Safeguards are proposed to reduce these risks.
The limited data indicate net cost savings may be realised with Advance Care Planning. Methodologically robust trials with clearly defined Advance Care Planning interventions are needed to make the costs and returns of Advance Care Planning transparent.
虽然越来越多的证据表明，预先护理计划有潜力增强患者自主权并改善临终时的护理质量，但尚不清楚它是否还能降低护理的净成本。
本研究旨在描述预先护理计划项目的成本影响，并讨论在此背景下产生的伦理冲突。
我们根据系统评价和Meta分析的首选报告项目声明进行了系统评价。
我们系统检索了PubMed、NHS EED、EURONHEED、Cochrane图书馆和EconLit数据库。我们纳入了实证研究（对研究类型无限制），这些研究调查了涉及专业协助的临终讨论的预先护理计划项目的成本影响。
七项研究符合我们的纳入标准。其中四项采用随机对照设计，一项采用前后设计，两项为观察性研究。六项研究发现，每位患者的护理成本有所降低，降低幅度在1041美元至64827美元之间，具体取决于研究期间和成本衡量方法。一项研究未发现成本差异。在预先护理计划干预、患者选择和所衡量的成本方面，研究差异很大，这可能解释了研究结果的一些差异。
审视预先护理计划对成本的影响会引发微妙的伦理问题。鉴于削减开支的压力不断增加，可能有人担心成本考量会过度影响敏感的沟通流程，从而危及患者自主权。建议采取保障措施以降低这些风险。
有限的数据表明预先护理计划可能实现净成本节约。需要进行方法学上稳健且预先护理计划干预明确界定的试验，以使预先护理计划的成本和回报透明化。
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