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.
Br J Cancer. 2018 Nov;119(10):1182-1190. doi: 10.1038/s41416-018-0303-7. Epub 2018 Oct 29.
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.
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.
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%).
A formal ACP intervention did not increase the likelihood that EoL care was consistent with patients' preferences.
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。
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。
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%）。
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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