Section of General Internal Medicine, VA Boston Healthcare System, Boston, Massachusetts2Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts3Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer.
Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, Massachusetts5Tufts Health Plan, Watertown, Massachusetts.
JAMA Intern Med. 2016 Aug 1;176(8):1095-102. doi: 10.1001/jamainternmed.2016.1200.
Efforts to improve end-of-life care have focused primarily on patients with cancer. High-quality end-of-life care is also critical for patients with other illnesses.
To compare patterns of end-of-life care and family-rated quality of care for patients dying with different serious illnesses.
DESIGN, SETTING, AND PARTICIPANTS: A retrospective cross-sectional study was conducted in all 146 inpatient facilities within the Veteran Affairs health system among patients who died in inpatient facilities between October 1, 2009, and September 30, 2012, with clinical diagnoses categorized as end-stage renal disease (ESRD), cancer, cardiopulmonary failure (congestive heart failure or chronic obstructive pulmonary disease), dementia, frailty, or other conditions. Data analysis was conducted from April 1, 2014, to February 10, 2016.
Palliative care consultations, do-not-resuscitate orders, death in inpatient hospices, death in the intensive care unit, and family-reported quality of end-of-life care.
Among 57 753 decedents, approximately half of the patients with ESRD, cardiopulmonary failure, or frailty received palliative care consultations (adjusted proportions, 50.4%, 46.7%, and 43.7%, respectively) vs 73.5% of patients with cancer and 61.4% of patients with dementia (P < .001). Approximately one-third of patients with ESRD, cardiopulmonary failure, or frailty (adjusted proportions, 32.3%, 34.1%, and 35.2%, respectively) died in the intensive care unit, more than double the rates among patients with cancer and those with dementia (13.4% and 8.9%, respectively) (P < .001). Rates of excellent quality of end-of-life care reported by 34 005 decedents' families were similar for patients with cancer and those with dementia (adjusted proportions, 59.2% and 59.3%; P = .61), but lower for patients with ESRD, cardiopulmonary failure, or frailty (54.8%, 54.8%, and 53.7%, respectively; all P ≤ .02 vs patients with cancer). This quality advantage was mediated by palliative care consultation, setting of death, and a code status of do-not-resuscitate; adjustment for these variables rendered the association between diagnosis and overall end-of-life care quality nonsignificant.
Family-reported quality of end-of-life care was significantly better for patients with cancer and those with dementia than for patients with ESRD, cardiopulmonary failure, or frailty, largely owing to higher rates of palliative care consultation and do-not-resuscitate orders and fewer deaths in the intensive care unit among patients with cancer and those with dementia. Increasing access to palliative care and goals of care discussions that address code status and preferred setting of death, particularly for patients with end-organ failure and frailty, may improve the overall quality of end-of-life care for Americans dying of these illnesses.
提高临终关怀质量的努力主要集中在癌症患者身上。对于患有其他疾病的患者来说，高质量的临终关怀也至关重要。
比较不同严重疾病患者的临终关怀模式和家庭对护理质量的评价。
设计、地点和参与者：这是一项回顾性的横截面研究，在退伍军人事务部医疗系统的所有 146 个住院病房中进行，研究对象为 2009 年 10 月 1 日至 2012 年 9 月 30 日期间在住院病房死亡的患者，临床诊断为终末期肾病（ESRD）、癌症、心肺衰竭（充血性心力衰竭或慢性阻塞性肺疾病）、痴呆、虚弱或其他疾病。数据分析于 2014 年 4 月 1 日至 2016 年 2 月 10 日进行。
姑息治疗咨询、不复苏医嘱、住院临终关怀死亡、重症监护病房死亡和家庭报告的临终关怀质量。
在 57753 名死者中，约有一半的 ESRD、心肺衰竭或虚弱患者接受了姑息治疗咨询（调整比例分别为 50.4%、46.7%和 43.7%），而癌症患者和痴呆患者的比例分别为 73.5%和 61.4%（P<0.001）。大约三分之一的 ESRD、心肺衰竭或虚弱患者（调整比例分别为 32.3%、34.1%和 35.2%）在重症监护病房死亡，这一比例是癌症患者和痴呆患者的两倍多（分别为 13.4%和 8.9%）（P<0.001）。34005 名死者家属报告的临终关怀质量良好，癌症患者和痴呆患者的比例相似（调整比例分别为 59.2%和 59.3%；P=0.61），而 ESRD、心肺衰竭或虚弱患者的比例较低（分别为 54.8%、54.8%和 53.7%；均 P≤0.02 与癌症患者相比）。这种质量优势是由姑息治疗咨询、死亡地点和不复苏医嘱决定的；调整这些变量后，诊断与整体临终关怀质量之间的关联不再显著。
癌症患者和痴呆患者的家庭报告的临终关怀质量明显优于 ESRD、心肺衰竭或虚弱患者，这主要是由于癌症患者和痴呆患者姑息治疗咨询和不复苏医嘱的比例较高，以及重症监护病房的死亡率较低。增加获得姑息治疗的机会，并开展关于医嘱和首选死亡地点的目标治疗讨论，特别是针对终末期器官衰竭和虚弱的患者，可能会提高美国人因这些疾病死亡的整体临终关怀质量。
