Department of Biomedicine and Prevention, University of Roma Tor Vergata, Roma, Italy; Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Torino, Italy.
Department of Public Health and Pediatric Sciences, University of Torino, Torino, Italy.
J Am Med Dir Assoc. 2019 Mar;20(3):249-261. doi: 10.1016/j.jamda.2018.10.001. Epub 2018 Nov 20.
Less aggressive end-of-life (EOL) care has been observed when health care professionals discuss approaching EOL and preferences about life-sustaining treatments with nursing home (NH) residents or their families. We performed a comprehensive systematic review to evaluate the association between health care professionals-residents and health care professionals-family EOL conversations and EOL care outcomes.
Systematic review with meta-analysis.
Seven databases were searched in December 2017 to find studies that focused on health care professionals-residents (without oncologic disease) and health care professionals-family EOL conversations and aimed to explore the impact of EOL conversations on resident's or family's EOL care outcomes.
Random effects meta-analyses with subsequent quality sensitivity analysis and meta-regression were performed to assess the effects of EOL conversations on the decision to limit or withdraw life-sustaining treatments. A funnel plot and Eagger test were used to assess publication bias.
16 studies were included in the qualitative and 7 in the quantitative synthesis. Health care professionals-family EOL conversations were positively associated with the family's decision to limit or withdraw life-sustaining treatments (odds ratio = 2.23, 95% confidence interval: 1.58-3.14). The overall effect of health care professionals-family EOL conversations on the family's decision to limit or withdraw life-sustaining treatments remained stable in the quality sensitivity analysis. In the meta-regression, family members with a higher level of education were less influenced by EOL conversations with health care professionals when making decisions about limiting or withdrawing life-sustaining treatments. No publication bias was detected (P = .4483).
CONCLUSIONS/IMPLICATIONS: This systematic review shows that EOL conversations promote palliative care. Structured conversations aimed at exploring NH resident preferences about EOL treatment should become routine. NH administrators should offer health care professionals regular training on EOL conversations, and resident-centered care that involves residents and their families in a shared decision-making process at EOL needs to be promoted.
当医护人员与疗养院（NH）居民或其家属讨论临终问题和对维持生命治疗的偏好时，观察到临终关怀的积极性降低。我们进行了全面的系统评价，以评估医护人员-居民和医护人员-家属的临终谈话与临终关怀结果之间的关系。
系统评价与荟萃分析。
2017 年 12 月，检索了 7 个数据库，以查找专注于医护人员-居民（无肿瘤疾病）和医护人员-家属临终谈话的研究，并旨在探讨临终谈话对居民或家属临终关怀结果的影响。
采用随机效应荟萃分析，随后进行质量敏感性分析和荟萃回归分析，以评估临终谈话对限制或停止维持生命治疗的决策的影响。使用漏斗图和 Eagger 检验评估发表偏倚。
16 项研究纳入定性综合分析，7 项研究纳入定量综合分析。医护人员-家属的临终谈话与家属决定限制或停止维持生命的治疗呈正相关（比值比=2.23，95%置信区间：1.58-3.14）。在质量敏感性分析中，医护人员-家属的临终谈话对家属决定限制或停止维持生命治疗的总体影响仍然稳定。在荟萃回归中，在做出限制或停止维持生命治疗的决策时，受教育程度较高的家属受与医护人员进行临终谈话的影响较小。未发现发表偏倚（P=0.4483）。
结论/意义：本系统评价表明，临终谈话促进了姑息治疗。应该将旨在探索 NH 居民对临终治疗偏好的结构化谈话作为常规做法。NH 管理人员应定期为医护人员提供关于临终谈话的培训，并应推广以居民为中心的关怀，让居民及其家属在临终时参与共同决策过程。
