Robinson Maisha T, Vickrey Barbara G, Holloway Robert G, Chong Kelly, Williams Linda S, Brook Robert H, Leng Mei, Parikh Punam, Zingmond David S
From the Department of Neurology (M.T.R.), Mayo Clinic, Jacksonville, FL; Department of Neurology (B.G.V.), David Geffen UCLA School of Medicine (R.H.B.), and Department of Medicine, Division of General Internal Medicine and Health Services Research (M.L., P.P., D.S.Z.), University of California, Los Angeles; Icahn School of Medicine at Mount Sinai (B.G.V.), New York; Department of Neurology (R.G.H.), University of Rochester, New York, NY; University of New Mexico School of Medicine (K.C.); Veterans Affairs HSR&D Center for Health Information and Communication (L.S.W.); Department of Neurology, Indiana University (L.S.W.); Regenstrief Institute, Inc. (L.S.W.); RAND Corporation (R.H.B.); Jonathan and Karin Fielding School of Public Health (R.H.B.); and Veterans Affairs Greater Los Angeles Healthcare System (D.S.Z.).
Neurology. 2016 May 31;86(22):2056-62. doi: 10.1212/WNL.0000000000002625. Epub 2016 Apr 8.
To measure the extent and timing of physicians' documentation of communication with patients and families regarding limitations on life-sustaining interventions, in a population cohort of adults who died within 30 days after hospitalization for ischemic stroke.
We used the California Office of Statewide Health Planning and Development Patient Discharge Database to identify a retrospective cohort of adults with ischemic strokes at all California acute care hospitals from December 2006 to November 2007. Of 326 eligible hospitals, a representative sample of 39 was selected, stratified by stroke volume and mortality. Medical records of 981 admissions were abstracted, oversampled on mortality and tissue plasminogen activator receipt. Among 198 patients who died by 30 days postadmission, overall proportions and timing of documented preferences were calculated; factors associated with documentation were explored.
Of the 198 decedents, mean age was 80 years, 78% were admitted from home, 19% had mild strokes, 11% received tissue plasminogen activator, and 42% died during the index hospitalization. Preferences about at least one life-sustaining intervention were recorded on 39% of patients: cardiopulmonary resuscitation 34%, mechanical ventilation 23%, nasogastric tube feeding 10%, and percutaneous enteral feeding 6%. Most discussions occurred within 5 days of death. Greater stroke severity was associated with increased in-hospital documentation of preferences (p < 0.05).
Documented discussions about limitations on life-sustaining interventions during hospitalization were low, even though this cohort died within 30 days poststroke. Improving the documentation of preferences may be difficult given the 2015 Centers for Medicare and Medicaid 30-day stroke mortality hospital performance measure that is unadjusted for patient preferences regarding life-sustaining interventions.
在因缺血性中风住院后30天内死亡的成年人群队列中，衡量医生记录与患者及其家属就维持生命干预措施限制进行沟通的程度和时间时间及时间。
我们使用加利福尼亚州全州卫生规划与发展办公室患者出院数据库，确定了2006年12月至2007年11月期间加利福尼亚州所有急性护理医院中缺血性中风成年患者的回顾性队列。在326家符合条件的医院中，选取了39家具有代表性的样本，按中风病例数和死亡率进行分层。抽取了981例入院病例的医疗记录，对死亡率和接受组织纤溶酶原激活剂治疗的情况进行了过度抽样。在198例入院后30天内死亡的患者中，计算记录偏好的总体比例和时间；探讨与记录相关的因素。
在198例死者中，平均年龄为80岁，78% 从家中入院，19% 为轻度中风，11% 接受了组织纤溶酶原激活剂治疗，42% 在首次住院期间死亡。39% 的患者记录了关于至少一种维持生命干预措施的偏好：心肺复苏34%，机械通气23%，鼻饲管喂养10%，经皮肠内喂养6%。大多数讨论发生在死亡前5天内。中风严重程度越高，住院期间偏好记录的可能性越大（p < 0.05）。
尽管该队列在中风后30天内死亡，但住院期间关于维持生命干预措施限制的记录讨论率较低。鉴于2015年医疗保险和医疗补助服务中心的30天中风死亡率医院绩效指标未根据患者对维持生命干预措施的偏好进行调整，改善偏好记录可能存在困难。
