Deptola Amber Zimmer, Riggs Jessica
1 Medicine Service, John Cochran VA Medical Center, St Louis, MO, USA.
2 Division of Medical Education, Department of Internal Medicine, Washington University in St. Louis, St Louis, MO, USA.
Am J Hosp Palliat Care. 2019 Jul;36(7):583-586. doi: 10.1177/1049909118824546. Epub 2019 Jan 17.
Despite an aging population and an increase in the prevalence of chronic severe illness, many patients will not have end-of-life care discussions with their outpatient physicians. This very likely contributes to considerable hospital utilization toward the end of life, without any clear benefit. At our medical center, we noticed a very high rate of floor-to-intensive care unit (ICU) transfers for patients with life-limiting illness and poor prognosis. We initiated a quality assessment and improvement project aimed at increasing goals-of-care conversations for high-risk patients early in their hospital stays. Patients were identified using a risk assessment score combined with presence of life-limiting illness and alerting the inpatient attending physician to the patient's severity of illness. Inpatient attending physicians were encouraged to expeditiously initiate and document goals-of-care discussions with their patients and families or to consult palliative care. Patient data were extracted retrospectively from high-risk patients prior to and during the intervention period. Analysis showed a significant increase in overall goals-of-care discussions and a significant reduction in floor-to-ICU transfers during initial admission. There was no change in mortality at 1 year, but there was a trend toward more in-home deaths for those patients who died within the year. Early inpatient goals-of-care conversations may reduce ICU utilization at index hospitalization and may reduce overall health-care utilization near the end of life.
尽管人口老龄化且慢性重症的患病率有所上升，但许多患者不会与门诊医生进行临终关怀讨论。这很可能导致临终时大量的医院资源利用，却没有任何明显益处。在我们的医疗中心，我们注意到患有危及生命疾病且预后不良的患者从普通病房转至重症监护病房（ICU）的比例非常高。我们启动了一项质量评估与改进项目，旨在让高危患者在住院早期更多地进行治疗目标的沟通。通过风险评估分数结合危及生命疾病的存在情况来识别患者，并提醒住院主治医生注意患者的疾病严重程度。鼓励住院主治医生迅速与患者及其家属展开并记录治疗目标的讨论，或咨询姑息治疗团队。在干预期之前和期间，从高危患者中回顾性提取患者数据。分析显示，总体治疗目标讨论显著增加，初次入院期间从普通病房转至ICU的情况显著减少。1年时死亡率没有变化，但在当年死亡的患者中，居家死亡的趋势有所增加。住院早期进行治疗目标的沟通可能会降低首次住院时ICU的利用率，并可能减少临终时的总体医疗资源利用。
