Agar Meera, Luckett Tim, Luscombe Georgina, Phillips Jane, Beattie Elizabeth, Pond Dimity, Mitchell Geoffrey, Davidson Patricia M, Cook Janet, Brooks Deborah, Houltram Jennifer, Goodall Stephen, Chenoweth Lynnette
Faculty of Health, University of Technology Sydney, Ultimo, New South Wales (NSW), Australia.
South Western Sydney Clinical School, University of New South Wales, Liverpool, NSW, Australia.
PLoS One. 2017 Aug 7;12(8):e0181020. doi: 10.1371/journal.pone.0181020. eCollection 2017.
Palliative care planning for nursing home residents with advanced dementia is often suboptimal. This study compared effects of facilitated case conferencing (FCC) with usual care (UC) on end-of-life care.
A two arm parallel cluster randomised controlled trial was conducted. The sample included people with advanced dementia from 20 Australian nursing homes and their families and professional caregivers. In each intervention nursing home (n = 10), Palliative Care Planning Coordinators (PCPCs) facilitated family case conferences and trained staff in person-centred palliative care for 16 hours per week over 18 months. The primary outcome was family-rated quality of end-of-life care (End-of-Life Dementia [EOLD] Scales). Secondary outcomes included nurse-rated EOLD scales, resident quality of life (Quality of Life in Late-stage Dementia [QUALID]) and quality of care over the last month of life (pharmacological/non-pharmacological palliative strategies, hospitalization or inappropriate interventions).
Two-hundred-eighty-six people with advanced dementia took part but only 131 died (64 in UC and 67 in FCC which was fewer than anticipated), rendering the primary analysis under-powered with no group effect seen in EOLD scales. Significant differences in pharmacological (P < 0.01) and non-pharmacological (P < 0.05) palliative management in last month of life were seen. Intercurrent illness was associated with lower family-rated EOLD Satisfaction with Care (coefficient 2.97, P < 0.05) and lower staff-rated EOLD Comfort Assessment with Dying (coefficient 4.37, P < 0.01). Per protocol analyses showed positive relationships between EOLD and staff hours to bed ratios, proportion of residents with dementia and staff attitudes.
FCC facilitates a palliative approach to care. Future trials of case conferencing should consider outcomes and processes regarding decision making and planning for anticipated events and acute illness.
Australian New Zealand Clinical Trial Registry ACTRN12612001164886.
为患有晚期痴呆症的养老院居民制定的姑息治疗计划往往不够理想。本研究比较了便利式病例讨论会（FCC）与常规护理（UC）对临终关怀的效果。
进行了一项双臂平行整群随机对照试验。样本包括来自20家澳大利亚养老院的晚期痴呆症患者及其家人和专业护理人员。在每家干预养老院（n = 10）中，姑息治疗计划协调员（PCPC）主持家庭病例讨论会，并在18个月内每周为员工提供16小时的以患者为中心的姑息治疗培训。主要结局是家庭评定的临终关怀质量（临终痴呆症[EOLD]量表）。次要结局包括护士评定的EOLD量表、居民生活质量（晚期痴呆症生活质量[QUALID]）以及生命最后一个月的护理质量（药物/非药物姑息治疗策略、住院或不适当干预）。
286名晚期痴呆症患者参与，但仅131人死亡（UC组64人，FCC组67人，低于预期），导致主要分析效力不足，EOLD量表未显示出组间效应。在生命的最后一个月，药物（P < 0.01）和非药物（P < 0.05）姑息治疗管理存在显著差异。并发疾病与较低的家庭评定EOLD护理满意度（系数2.97，P < 0.05）和较低的员工评定EOLD临终舒适度评估（系数4.37，P < 0.01）相关。按方案分析显示，EOLD与员工卧床时间比例、痴呆症居民比例和员工态度之间存在正相关关系。
FCC促进了姑息治疗方法。未来的病例讨论会试验应考虑决策以及预期事件和急性疾病规划的结局和过程。
澳大利亚新西兰临床试验注册中心ACTRN12612001164886。
