Sinclair Craig, Auret Kirsten Anne, Evans Sharon Frances, Williamson Fiona, Dormer Siobhan, Wilkinson Anne, Greeve Kim, Koay Audrey, Price Dot, Brims Fraser
Rural Clinical School of Western Australia, University of Western Australia, Albany, Western Australia, Australia.
Rural Clinical School of Western Australia, University of Western Australia, Perth, Western Australia, Australia.
BMJ Open. 2017 Feb 24;7(2):e013415. doi: 10.1136/bmjopen-2016-013415.
Advance care planning (ACP) clarifies goals for future care if a patient becomes unable to communicate their own preferences. However, ACP uptake is low, with discussions often occurring late. This study assessed whether a systematic nurse-led ACP intervention increases ACP in patients with advanced respiratory disease.
A multicentre open-label randomised controlled trial with preference arm.
Metropolitan teaching hospital and a rural healthcare network.
149 participants with respiratory malignancy, chronic obstructive pulmonary disease or interstitial lung disease.
Nurse facilitators offered facilitated ACP discussions, prompted further discussions with doctors and loved ones, and assisted participants to appoint a substitute medical decision-maker (SDM) and complete an advance directive (AD).
The primary measure was formal (AD or SDM) or informal (discussion with doctor) ACP uptake assessed by self-report (6 months) and medical notes audit. Secondary measures were the factors predicting baseline readiness to undertake ACP, and factors predicting postintervention ACP uptake in the intervention arm.
At 6 months, formal ACP uptake was significantly higher (p<0.001) in the intervention arm (54/106, 51%), compared with usual care (6/43, 14%). ACP discussions with doctors were also significantly higher (p<0.005) in the intervention arm (76/106, 72%) compared with usual care (20/43, 47%). Those with a strong preference for the intervention were more likely to complete formal ACP documents than those randomly allocated. Increased symptom burden and preference for the intervention predicted later ACP uptake. Social support was positively associated with ACP discussion with loved ones, but negatively associated with discussion with doctors.
Nurse-led facilitated ACP is acceptable to patients with advanced respiratory disease and effective in increasing ACP discussions and completion of formal documents. Awareness of symptom burden, readiness to engage in ACP and relevant psychosocial factors may facilitate effective tailoring of ACP interventions and achieve greater uptake.
ACTRN12614000255684.
如果患者无法表达自己的偏好，预先护理计划（ACP）可明确未来护理的目标。然而，ACP的采用率较低，讨论往往发生在晚期。本研究评估了由护士主导的系统性ACP干预措施是否能提高晚期呼吸系统疾病患者的ACP水平。
一项多中心开放标签随机对照试验，设有偏好组。
都市教学医院和农村医疗网络。
149名患有呼吸恶性肿瘤、慢性阻塞性肺疾病或间质性肺疾病的参与者。
护士协调员提供便利的ACP讨论，促使与医生和亲人进行进一步讨论，并协助参与者指定替代医疗决策者（SDM）并完成预先指示（AD）。
主要指标是通过自我报告（6个月）和病历审核评估的正式（AD或SDM）或非正式（与医生讨论）ACP采用情况。次要指标是预测基线时进行ACP准备程度的因素，以及预测干预组干预后ACP采用情况的因素。
在6个月时，干预组的正式ACP采用率（54/106，51%）显著高于常规护理组（6/43，14%）（p<0.001）。与常规护理组（20/43，47%）相比，干预组与医生的ACP讨论也显著更多（p<0.005）（76/106，72%）。与随机分配的患者相比，强烈倾向于接受干预的患者更有可能完成正式的ACP文件。症状负担增加和对干预的偏好预测了后期的ACP采用情况。社会支持与与亲人的ACP讨论呈正相关，但与与医生的讨论呈负相关。
由护士主导的便利ACP对晚期呼吸系统疾病患者是可接受的，并且在增加ACP讨论和完成正式文件方面是有效的。了解症状负担、参与ACP的准备程度和相关的社会心理因素可能有助于有效调整ACP干预措施并实现更高的采用率。
ACTRN12614000255684。
