Fried Terri R, Zenoni Maria, Iannone Lynne, O'Leary John, Fenton Brenda T
Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven, Connecticut.
Department of Medicine, Yale School of Medicine, New Haven, Connecticut.
J Am Geriatr Soc. 2017 Aug;65(8):1712-1718. doi: 10.1111/jgs.14858. Epub 2017 Mar 20.
A key objective of advance care planning (ACP) is improving surrogates' knowledge of patients' treatment goals. Little is known about whether ACP outside of a trial accomplishes this. The objective was to examine patient and surrogate reports of ACP engagement and associations with surrogate knowledge of goals.
Cohort study SETTING: Primary care in a Veterans Affairs Medical Center.
350 community-dwelling veterans age ≥55 years and the individual they would choose to make medical decisions on their behalf, interviewed separately.
Treatment goals were assessed by veterans' ratings of 3 health states: severe physical disability, cognitive disability, and pain, as an acceptable or unacceptable result of treatment for severe illness. Surrogates had knowledge if they correctly predicted all 3 responses. Veterans and surrogates were asked about living will and health care proxy completion and communication about life-sustaining treatment and quality versus quantity of life (QOL).
Over 40% of dyads agreed that the veteran had not completed a living will or health care proxy and that there was no QOL communication. For each activity, sizeable proportions (18-34%) disagreed about participation. In dyads who agreed QOL communication had occurred, 30% of surrogates had knowledge, compared to 21% in dyads who agreed communication had not occurred and 15% in dyads who disagreed (P = .01). This relationship persisted in multivariable analysis. Agreement about other ACP activities was not associated with knowledge.
Disagreement about ACP participation was common. Agreement about communication regarding QOL was modestly associated with surrogate knowledge of treatment goals. Eliciting surrogates' perspectives is critical to ACP. Even dyads who agree about participation may need additional support for successful engagement.
预先护理计划（ACP）的一个关键目标是提高替代决策者对患者治疗目标的了解。对于试验之外的ACP是否能实现这一目标，人们了解甚少。本研究的目的是调查患者和替代决策者关于参与ACP的报告以及与替代决策者目标知识的关联。
队列研究
退伍军人事务医疗中心的初级保健部门
350名年龄≥55岁的社区居住退伍军人以及他们选择的代表他们做出医疗决策的个人，分别进行访谈。
通过退伍军人对三种健康状态（严重身体残疾、认知残疾和疼痛）的评分来评估治疗目标，将其作为严重疾病治疗的可接受或不可接受结果。如果替代决策者能正确预测所有三种反应，则表明其具备相关知识。向退伍军人及替代决策者询问生前遗嘱和医疗保健代理人的完成情况，以及关于维持生命治疗和生活质量与数量（QOL）的沟通情况。
超过40%的配对组合认为退伍军人未完成生前遗嘱或医疗保健代理人指定，且没有关于生活质量的沟通。对于每项活动，相当比例（18 - 34%）的配对组合在参与情况上存在分歧。在认为已进行生活质量沟通的配对组合中，30%的替代决策者具备相关知识，相比之下，认为未进行沟通的配对组合中这一比例为21%，存在分歧的配对组合中为15%（P = 0.01）。这种关系在多变量分析中持续存在。关于其他ACP活动的一致性与知识水平无关。
在ACP参与情况上存在分歧很常见。关于生活质量沟通的一致性与替代决策者对治疗目标的了解适度相关。了解替代决策者的观点对ACP至关重要。即使在参与情况上达成一致的配对组合，可能也需要额外支持才能成功参与。
