Department of Medicine, Blood and Marrow Transplantation, Stanford University, Stanford, California.
Quantitative Sciences Unit, Department of Medicine, Stanford University, Stanford, California.
Biol Blood Marrow Transplant. 2018 May;24(5):1035-1040. doi: 10.1016/j.bbmt.2018.01.014. Epub 2018 Jan 31.
Allogeneic hematopoietic cell transplantation (HCT) is associated with significant morbidity and mortality, making advance care planning (ACP) and management especially important in this patient population. A paucity of data exists on the utilization of ACP among allogeneic HCT recipients and the relationship between ACP and intensity of healthcare utilization in these patients. We performed a retrospective review of patients receiving allogeneic HCT at our institution from 2008 to 2015 who had subsequently died after HCT. Documentation and timing of advance directive (AD) completion were abstracted from the electronic medical record. Outcomes of interest included use of intensive care unit (ICU) level of care at any time point after HCT, within 30 days of death, and within 14 days of death; use of mechanical ventilation at any time after HCT; and location of death. Univariate logistic regression was performed to explore associations between AD completion and each outcome. Of the 1031 patients who received allogeneic HCT during the study period, 422 decedents (41%) were included in the analysis. Forty-four percent had AD documentation prior to death. Most patients (69%) indicated that if terminally ill, they did not wish to be subjected to life-prolonging treatment attempts. Race/ethnicity was significantly associated with AD documentation, with non-Hispanic white patients documenting ADs more frequently (51%) compared with Hispanic (22%) or Asian patients (35%; P = .0007). Patients with ADs were less likely to use the ICU during the transplant course (41% for patients with ADs versus 52% of patients without ADs; P = .03) and also were less likely to receive mechanical ventilation at any point after transplantation (21% versus 37%, P < .001). AD documentation was also associated with decreased ICU use at the end of life; relative to patients without ADs, patients with ADs were more likely to die at home or in hospital as opposed to in the ICU (odds ratio, .44; 95% confidence interval, .27 to .72). ACP remains underused in allogeneic HCT. Adoption of a systematic practice to standardize AD documentation as part of allogeneic HCT planning has the potential to significantly reduce ICU use and mechanical ventilation while improving quality of care at end of life in HCT recipients.
异基因造血细胞移植（HCT）与显著的发病率和死亡率相关，这使得预先护理计划（ACP）和管理在这类患者中尤为重要。关于异基因 HCT 受者中 ACP 的利用以及 ACP 与这些患者医疗保健利用强度之间的关系，目前数据有限。我们对 2008 年至 2015 年在我院接受异基因 HCT 后死亡的患者进行了回顾性研究。从电子病历中提取预先指示（AD）完成的文件和时间。感兴趣的结果包括在 HCT 后任何时间点、死亡后 30 天内和死亡后 14 天内使用重症监护病房（ICU）级别的护理；在 HCT 后任何时间使用机械通气；以及死亡地点。使用单变量逻辑回归探讨 AD 完成与每个结果之间的关联。在研究期间接受异基因 HCT 的 1031 名患者中，有 422 名死者（41%）纳入分析。44%的患者在死亡前有 AD 记录。大多数患者（69%）表示，如果生命垂危，他们不希望接受延长生命的治疗尝试。种族/民族与 AD 记录显著相关，非西班牙裔白人患者记录 AD 的频率更高（51%），而西班牙裔（22%）或亚裔患者（35%）较低（P = .0007）。有 AD 的患者在移植过程中使用 ICU 的可能性较低（有 AD 的患者为 41%，无 AD 的患者为 52%；P = .03），在移植后任何时间接受机械通气的可能性也较低（有 AD 的患者为 21%，无 AD 的患者为 37%；P < .001）。AD 记录也与生命末期 ICU 使用减少相关；与没有 AD 的患者相比，有 AD 的患者更有可能在家中或医院而不是 ICU 死亡（比值比，.44；95%置信区间，.27 至.72）。在异基因 HCT 中，ACP 的使用仍然不足。采用系统实践将 AD 记录标准化为异基因 HCT 计划的一部分，有可能显著减少 ICU 使用和机械通气，同时提高 HCT 受者生命末期的护理质量。
