Kurella Tamura Manjula, Montez-Rath Maria E, Hall Yoshio N, Katz Ronit, O'Hare Ann M
Geriatric Research and Education Clinical Center, Palo Alto Veterans Affairs Health Care System, Palo Alto, California.
Division of Nephrology, Stanford University School of Medicine, Palo Alto, California.
Clin J Am Soc Nephrol. 2017 Mar 7;12(3):435-442. doi: 10.2215/CJN.07510716. Epub 2017 Jan 5.
Little is known about the relation between the content of advance directives and downstream treatment decisions among patients receiving maintenance dialysis. In this study, we determined the prevalence of advance directives specifying treatment limitations and/or surrogate decision-makers in the last year of life and their association with end-of-life care among nursing home residents.
DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Using national data from 2006 to 2007, we compared the content of advance directives among 30,716 nursing home residents receiving dialysis to 30,825 nursing home residents with other serious illnesses during the year before death. Among patients receiving dialysis, we linked the content of advance directives to Medicare claims to ascertain site of death and treatment intensity in the last month of life.
In the last year of life, 36% of nursing home residents receiving dialysis had a treatment-limiting directive, 22% had a surrogate decision-maker, and 13% had both in adjusted analyses. These estimates were 13%-27%, 5%-11%, and 6%-13% lower, respectively, than for decedents with other serious illnesses. For patients receiving dialysis who had both a treatment-limiting directive and surrogate decision-maker, the adjusted frequency of hospitalization, intensive care unit admission, intensive procedures, and inpatient death were lower by 13%, 17%, 13%, and 14%, respectively, and hospice use and dialysis discontinuation were 5% and 7% higher compared with patients receiving dialysis lacking both components.
Among nursing home residents receiving dialysis, treatment-limiting directives and surrogates were associated with fewer intensive interventions and inpatient deaths, but were in place much less often than for nursing home residents with other serious illnesses.
对于接受维持性透析的患者，生前预嘱内容与后续治疗决策之间的关系鲜为人知。在本研究中，我们确定了在生命最后一年中指定治疗限制和/或替代决策者的生前预嘱的患病率，以及它们与疗养院居民临终关怀的关联。
设计、地点、参与者及测量方法：利用2006年至2007年的全国数据，我们比较了30716名接受透析的疗养院居民与30825名患有其他严重疾病的疗养院居民在死亡前一年的生前预嘱内容。在接受透析的患者中，我们将生前预嘱内容与医疗保险理赔记录相联系，以确定死亡地点和生命最后一个月的治疗强度。
在生命的最后一年，接受透析的疗养院居民中，36%有治疗限制指令，22%有替代决策者，在调整分析中，13%两者都有。这些估计值分别比患有其他严重疾病的死者低13%-27%、5%-11%和6%-13%。对于同时有治疗限制指令和替代决策者的接受透析的患者，住院、重症监护病房入院、强化治疗程序和住院死亡的调整频率分别降低了13%、17%、13%和14%，临终关怀的使用和透析中断率分别比两者都没有的接受透析的患者高5%和7%。
在接受透析的疗养院居民中,治疗限制指令和替代决策者与较少的强化干预措施和住院死亡相关，但比患有其他严重疾病的疗养院居民的使用频率要低得多。
