一项针对不可治愈癌症患者的预先医疗照护计划干预的随机对照试验。
A randomised controlled trial of an advance care planning intervention for patients with incurable cancer.
机构信息
Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), School of Psychology and Department of Medicine, University of Sydney, Sydney, NSW, Australia.
Mel & Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona, USA.
出版信息
Br J Cancer. 2018 Nov;119(10):1182-1190. doi: 10.1038/s41416-018-0303-7. Epub 2018 Oct 29.
BACKGROUND
We modified and evaluated an advance care planning (ACP) intervention, which had been shown to improve compliance with patient's end of life (EoL) wishes, in a different patient population.
METHODS
Patients with incurable cancer, and a Family Member (FM), were randomised one-to-one to usual care or usual care plus an ACP intervention, between April 2014 and January 2017. Oncologists and participants were non-blinded. ACP was based on the Respecting Patient Choices model, with an offer to provide individualised ranges for typical, best-case and worst-case scenarios for survival time. Seven facilitators (two oncology nurses, two nurses and three allied health professionals) delivered the intervention within 2 weeks of study enrolment. The primary outcome measure, assessed by interviewing the FM 3 months after patient death, was the FM perception that the patient's wishes were discussed, and met.
RESULTS
Six hundred and sixty-five patients from seven Australian metropolitan oncology centres were referred for consideration by their oncologists, 444 (67%) met the study inclusion criteria and were approached by a study researcher. Two hundred and eight patients (47%) and their FM entered the trial as dyads. Fifty-three (46%) dyads in the ACP group and 63 (54%) dyads in the usual-care group had complete primary outcome data (p = 0.16). Seventy-nine patients and 53 FMs attended an ACP discussion. Mean length of discussion was 57 min. FMs from 23 (43%) dyads allocated to ACP and 21 (33%) dyads allocated usual care reported the patient's EoL wishes were discussed and met (difference 10%, 95% CI: -2 to 8, p = 0.27). There were no differences in EoL care received, patient satisfaction with care; FM satisfaction with care or with death; or FM well being. Rates of palliative care referral were high in both groups (97% vs 96%).
CONCLUSIONS
A formal ACP intervention did not increase the likelihood that EoL care was consistent with patients' preferences.
背景
我们对一项预先医疗照护计划（ACP）干预措施进行了修改和评估，该措施已被证明可提高患者临终愿望的遵从度，其干预对象为另一批患者群体。
方法
2014 年 4 月至 2017 年 1 月期间，我们将患有不治之症的癌症患者及其家属（FM）进行一对一随机分组，分为常规护理组或常规护理加 ACP 干预组。肿瘤医生和参与者均无法获知分组情况。ACP 基于尊重患者选择模型，提供个体化的典型、最佳和最差存活时间范围。7 名促进者（2 名肿瘤护士、2 名护士和 3 名联合健康专业人员）在研究入组后 2 周内提供干预措施。主要结局指标是通过采访 FM 在患者死亡后 3 个月进行评估，即 FM 认为患者的意愿已进行讨论并得到满足。
结果
来自澳大利亚 7 个大都市肿瘤中心的 665 名患者由其肿瘤医生推荐考虑，其中 444 名（67%）符合研究纳入标准，并由研究人员进行了接触。208 名患者（47%）及其 FM 作为对子进入试验。ACP 组 53 对（46%）和常规护理组 63 对（54%）对子完成了完整的主要结局数据（p=0.16）。79 名患者和 53 名 FM 参加了 ACP 讨论。讨论平均时长为 57 分钟。23 对（43%）分配到 ACP 的患者及其 FM 报告说，已讨论并满足了患者的临终愿望，21 对（33%）分配到常规护理的患者及其 FM 报告说，已讨论并满足了患者的临终愿望（差异 10%，95%CI：-2 至 8，p=0.27）。在接受的临终关怀服务、患者对护理的满意度、FM 对护理的满意度或对死亡的满意度、或 FM 的幸福感方面均无差异。两组中接受姑息治疗转诊的比例均很高（97% vs 96%）。
结论
正式的 ACP 干预并不能增加临终关怀服务符合患者意愿的可能性。
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