Rocque Gabrielle B, Dionne-Odom J Nicholas, Sylvia Huang Chao-Hui, Niranjan Soumya J, Williams Courtney P, Jackson Bradford E, Halilova Karina I, Kenzik Kelly M, Bevis Kerri S, Wallace Audrey S, Lisovicz Nedra, Taylor Richard A, Pisu Maria, Partridge Edward E, Butler Thomas W, Briggs Linda A, Kvale Elizabeth A
Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, Alabama, USA; Division of Hematology and Oncology, University of Alabama at Birmingham, Birmingham, Alabama, USA.
School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama, USA.
J Pain Symptom Manage. 2017 Apr;53(4):682-692. doi: 10.1016/j.jpainsymman.2016.11.012. Epub 2017 Jan 3.
Advance care planning (ACP) improves alignment between patient preferences for life-sustaining treatment and care received at end of life (EOL).
To evaluate implementation of lay navigator-led ACP.
A convergent, parallel mixed-methods design was used to evaluate implementation of navigator-led ACP across 12 cancer centers. Data collection included 1) electronic navigation records, 2) navigator surveys (n = 45), 3) claims-based patient outcomes (n = 820), and 4) semistructured navigator interviews (n = 26). Outcomes of interest included 1) the number of ACP conversations completed, 2) navigator self-efficacy, 3) patient resource utilization, hospice use, and chemotherapy at EOL, and 4) navigator-perceived barriers and facilitators to ACP.
From June 1, 2014 to December 31, 2015, 50 navigators completed Respecting Choices First Steps ACP Facilitator training. Navigators approached 18% of patients (1319/8704); 481 completed; 472 in process; 366 declined. Navigators were more likely to approach African American patients than Caucasian patients (20% vs. 14%, P < 0.001). Significant increases in ACP self-efficacy were observed after training. The mean score for feeling prepared to conduct ACP conversations increased from 5.6/10 to 7.5/10 (P < 0.001). In comparison with patients declining ACP participation (n = 171), decedents in their final 30 days of life who engaged in ACP (n = 437) had fewer hospitalizations (46% vs. 56%, P = 0.02). Key facilitators of successful implementation included physician buy-in, patient readiness, and prior ACP experience; barriers included space limitations, identifying the "right" time to start conversations, and personal discomfort discussing EOL.
A navigator-led ACP program was feasible and may be associated with lower rates of resource utilization near EOL.
预先护理计划（ACP）有助于使患者对维持生命治疗的偏好与临终（EOL）时接受的护理保持一致。
评估由非专业导航员主导的ACP的实施情况。
采用聚合性平行混合方法设计，以评估在12个癌症中心实施的由导航员主导的ACP。数据收集包括：1）电子导航记录；2）导航员调查（n = 45）；3）基于索赔的患者结局（n = 820）；4）半结构化的导航员访谈（n = 26）。感兴趣的结局包括：1）完成的ACP对话数量；2）导航员的自我效能感；3）患者的资源利用情况、临终时使用临终关怀服务和化疗的情况；4）导航员所感知到的ACP实施障碍和促进因素。
2014年6月1日至2015年12月31日，50名导航员完成了“尊重选择第一步”ACP促进者培训。导航员接触了18%的患者（1319/8704）；481名患者完成了ACP；472名患者正在进行中；366名患者拒绝了。与白人患者相比，导航员更有可能接触非裔美国患者（20%对14%，P < 0.001）。培训后，ACP自我效能感显著提高。准备进行ACP对话的感觉的平均得分从5.6/10提高到7.5/10（P < 0.001）。与拒绝参与ACP的患者（n = 171）相比，在生命最后30天参与ACP的死者（n = 437）住院次数更少（46%对56%，P = 0.02）。成功实施的关键促进因素包括医生的支持、患者的意愿以及先前的ACP经验；障碍包括空间限制、确定开始对话的“合适”时间以及讨论临终问题时的个人不适感。
由导航员主导的ACP项目是可行的，并且可能与临终时较低的资源利用率相关。
