van der Steen Jenny T, Di Giulio Paola, Giunco Fabrizio, Monti Massimo, Gentile Simona, Villani Daniele, Finetti Silvia, Pettenati Francesca, Charrier Lorena, Toscani Franco
1 Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, the Netherlands.
2 Department of Primary and Community Care, Radboud university medical center, Nijmegen, the Netherlands.
Am J Hosp Palliat Care. 2018 Mar;35(3):423-430. doi: 10.1177/1049909117709002. Epub 2017 May 22.
Comfort may be an appropriate goal in advanced dementia. Longitudinal studies on physician decision-making and discomfort assessed by direct observation are rare, and intravenous rehydration therapy is controversial.
To assess treatment decisions and discomfort in patients with advanced dementia and pneumonia and to compare by intravenous rehydration therapy, we used data from the observational multicenter Italian End of Life Observatory-Prospective Study On DEmentia patients Care. We analyzed 109 episodes of pneumonia, which involved decisions in 77 nursing home patients with Functional Assessment Staging Tool stage 7. We assessed decisions, decision-making, and treatments every fortnight. Trained observers assessed discomfort with the Discomfort Scale-Dementia Alzheimer Type (DS-DAT).
Most decisions referred to treatment with antibiotics (90%; 98 of 109) and intravenous rehydration therapy (53%; 58 of 109), but hospitalization was rare (1%). Selecting decisions with antibiotics, with rehydration therapy, the prognosis was more frequently <15 days (34% vs 5% without rehydration therapy; P = .001), and a goal to reduce symptoms/suffering was more common (96% vs 74%; P = .005) while there was no difference in striving for life prolongation (a minority). With rehydration therapy, the decision was more often discussed with family rather than communicated only. Mean DS-DAT scores over time proximate to the first decision ranged between 9.2 and 10.5.
Italian nursing home patients with advanced dementia and pneumonia frequently received invasive rehydration therapy in addition to antibiotics, however, mostly with a palliative intent. Discomfort was high overall and symptom relief may be improved. Relations between invasive rehydration therapy and discomfort need further study.
舒适可能是晚期痴呆症患者的一个恰当目标。关于医生决策以及通过直接观察评估不适情况的纵向研究很少见，并且静脉补液治疗存在争议。
为了评估晚期痴呆症合并肺炎患者的治疗决策和不适情况，并通过静脉补液治疗进行比较，我们使用了来自意大利临终观察站 - 痴呆患者护理前瞻性多中心观察研究的数据。我们分析了109例肺炎病例，这些病例涉及77名处于功能评估分期工具第7阶段的养老院患者的决策。我们每两周评估一次决策、决策过程和治疗情况。经过培训的观察者使用痴呆型阿尔茨海默病不适量表（DS - DAT）评估不适情况。
大多数决策涉及抗生素治疗（90%；109例中的98例）和静脉补液治疗（53%；109例中的58例），但住院情况很少见（1%）。在选择使用抗生素和补液治疗的决策中，预后小于15天的情况更常见（34%对未进行补液治疗的5%；P = 0.001），并且减轻症状/痛苦的目标更常见（96%对74%；P = 0.005），而在追求延长生命方面没有差异（少数情况）。进行补液治疗时，决策更多地是与家属讨论而不是仅进行告知。在首次决策附近时间段内的平均DS - DAT评分在9.2至10.5之间。
意大利养老院中患有晚期痴呆症和肺炎的患者除了接受抗生素治疗外，还经常接受侵入性补液治疗，然而，大多是出于姑息治疗目的。总体不适程度较高，症状缓解情况可能有待改善。侵入性补液治疗与不适之间的关系需要进一步研究。
