采用多状态马尔可夫模型研究终末期癌症患者生命最后 6 个月的预后意识转变。
Transitions in Prognostic Awareness Among Terminally Ill Cancer Patients in Their Last 6 Months of Life Examined by Multi-State Markov Modeling.
机构信息
Department of Nursing, University of Kang Ning, Taipei and Graduate Institute of Clinical Medical Science, Chang Gung University, Tao-Yuan, Taiwan.
Department of International Business, Soochow University, Taipei, Taiwan.
出版信息
Oncologist. 2017 Sep;22(9):1135-1142. doi: 10.1634/theoncologist.2017-0068. Epub 2017 Jul 6.
BACKGROUND
Developing accurate prognostic awareness, a cornerstone of preference-based end-of-life (EOL) care decision-making, is a dynamic process involving more prognostic-awareness states than knowing or not knowing. Understanding the transition probabilities and time spent in each prognostic-awareness state can help clinicians identify trigger points for facilitating transitions toward accurate prognostic awareness. We examined transition probabilities in distinct prognostic-awareness states between consecutive time points in 247 cancer patients' last 6 months and estimated the time spent in each state.
METHODS
Prognostic awareness was categorized into four states: (a) unknown and not wanting to know, state 1; (b) unknown but wanting to know, state 2; (c) inaccurate awareness, state 3; and (d) accurate awareness, state 4. Transitional probabilities were examined by multistate Markov modeling.
RESULTS
Initially, 59.5% of patients had accurate prognostic awareness, whereas the probabilities of being in states 1-3 were 8.1%, 17.4%, and 15.0%, respectively. Patients' prognostic awareness generally remained unchanged (probabilities of remaining in the same state: 45.5%-92.9%). If prognostic awareness changed, it tended to shift toward higher prognostic-awareness states (probabilities of shifting to state 4 were 23.2%-36.6% for patients initially in states 1-3, followed by probabilities of shifting to state 3 for those in states 1 and 2 [9.8%-10.1%]). Patients were estimated to spend 1.29, 0.42, 0.68, and 3.61 months in states 1-4, respectively, in their last 6 months.
CONCLUSION
Terminally ill cancer patients' prognostic awareness generally remained unchanged, with a tendency to become more aware of their prognosis. Health care professionals should facilitate patients' transitions toward accurate prognostic awareness in a timely manner to promote preference-based EOL decisions.
IMPLICATIONS FOR PRACTICE
Terminally ill Taiwanese cancer patients' prognostic awareness generally remained stable, with a tendency toward developing higher states of awareness. Health care professionals should appropriately assess patients' readiness for prognostic information and respect patients' reluctance to confront their poor prognosis if they are not ready to know, but sensitively coach them to cultivate their accurate prognostic awareness, provide desired and understandable prognostic information for those who are ready to know, and give direct and honest prognostic information to clarify any misunderstandings for those with inaccurate awareness, thus ensuring that they develop accurate and realistic prognostic knowledge in time to make end-of-life care decisions.
背景
发展准确的预后意识是基于偏好的临终关怀决策的基石，这是一个动态的过程，涉及到比知道或不知道更多的预后意识状态。了解每个预后意识状态的转移概率和花费的时间可以帮助临床医生确定促进向准确预后意识转变的触发点。我们在 247 名癌症患者生命最后 6 个月的连续时间点检查了不同预后意识状态之间的转移概率，并估计了每个状态所花费的时间。
方法
预后意识分为四个状态：(a) 未知且不想知道，状态 1；(b) 未知但想知道，状态 2；(c) 不准确的意识，状态 3；和(d) 准确的意识，状态 4。通过多状态马尔可夫模型检查转移概率。
结果
最初，59.5%的患者具有准确的预后意识，而处于状态 1-3 的概率分别为 8.1%、17.4%和 15.0%。患者的预后意识通常保持不变（处于同一状态的概率：45.5%-92.9%）。如果预后意识发生变化，它往往会向更高的预后意识状态转移（对于最初处于状态 1-3 的患者，转移到状态 4 的概率为 23.2%-36.6%，而对于处于状态 1 和 2 的患者，转移到状态 3 的概率为 9.8%-10.1%）。患者在生命的最后 6 个月中分别估计会在状态 1-4 中度过 1.29、0.42、0.68 和 3.61 个月。
结论
终末期癌症患者的预后意识通常保持不变，倾向于更了解自己的预后。医疗保健专业人员应及时促进患者向准确的预后意识转变，以促进基于偏好的临终关怀决策。
意义
台湾终末期癌症患者的预后意识通常保持稳定，有向更高意识状态发展的趋势。医疗保健专业人员应适当评估患者对预后信息的准备情况，并尊重患者不愿意面对不良预后的情况，如果他们还没有准备好了解，但要敏感地指导他们培养准确的预后意识，为那些准备好了解的人提供所需的、可理解的预后信息，并直接、诚实地提供预后信息，以澄清那些预后意识不准确的人的任何误解，从而确保他们及时获得准确和现实的预后知识，以便做出临终关怀决策。
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