Département de Médecine Générale, Faculté de Médecine, Université de Nantes, Nantes, France.
J Am Geriatr Soc. 2019 Jan;67(1):164-171. doi: 10.1111/jgs.15630. Epub 2018 Dec 3.
To comprehensively assess the effect of a living will on end-of-life care.
Systematic review with narrative analysis following Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology.
All interventional and observational studies were included, excepting those with fictive cases. Included studies were conducted in adults with and without living wills, excluding individuals with specific psychiatric living wills.
Two authors independently extracted study and participant characteristics and outcomes related to end-of-life care (place of death, hospitalization and intensive care unit management, life-sustaining treatments, restricted care). Risk of bias was assessed using the Risk Of Bias In Non-randomized Studies of Interventions tool.
From 7,596 records identified, 28 observational studies were included, 19 conducted in the United States, 7 in Europe, and 1 each in Canada and Australia. Place of death was assessed in 14 studies, life-sustaining treatments in 13, decision for restricted care in 12, and hospitalization in 8. Risk of bias was serious for 26 studies and moderate for 2. Twenty-one studies reported significantly less medical management for individuals with a living will, 3 reported more medical management, and the difference was not significant in 37.
Methodological quality of included studies was insufficient to offer reliable results. The effect of living wills appears limited in view of the importance and direction of potential biases. Further studies including larger populations, considering main confounding factors, and documenting the real presence of a living will in medical records are necessary to reach stronger conclusions on the effect of living wills on end-of-life care. J Am Geriatr Soc 67:164-171, 2019.
全面评估生前预嘱对临终关怀的影响。
系统评价，采用系统评价和荟萃分析首选报告项目的叙述性分析方法。
纳入的研究均为干预性和观察性研究，除外虚构病例的研究。纳入的研究对象为有和没有生前预嘱的成年人，不包括有特定精神科生前预嘱的个体。
两名作者独立提取与临终关怀相关的研究和参与者特征及结局（死亡地点、住院和重症监护病房管理、生命支持治疗、限制治疗）。使用干预措施非随机研究的偏倚风险评估工具评估偏倚风险。
从 7596 条记录中筛选出 28 项观察性研究，其中 19 项在美国进行，7 项在欧洲进行，1 项在加拿大和澳大利亚进行。14 项研究评估了死亡地点，13 项研究评估了生命支持治疗，12 项研究评估了限制治疗决策，8 项研究评估了住院治疗。26 项研究的偏倚风险较高，2 项研究的偏倚风险为中度。21 项研究报告称有生前预嘱的个体接受的医疗管理明显较少，3 项研究报告称接受的医疗管理较多，37 项研究的差异无统计学意义。
纳入研究的方法学质量不足，无法提供可靠的结果。鉴于潜在偏倚的重要性和方向，生前预嘱的效果似乎有限。需要进一步开展包括更大人群的研究，考虑主要混杂因素，并在医疗记录中记录生前预嘱的真实存在，以便就生前预嘱对临终关怀的影响得出更强有力的结论。美国老年学会杂志 67:164-171,2019。
