Reynolds Department of Geriatric Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma.
Multicampus Program in Geriatric Medicine and Gerontology, David Geffen School Medicine, University of California, Los Angeles, California.
J Am Geriatr Soc. 2019 Mar;67(3):443-448. doi: 10.1111/jgs.15769. Epub 2019 Jan 24.
BACKGROUND/OBJECTIVES: Although Alzheimer disease and other dementias are life limiting, only a minority of these patients or their proxy decision makers participate in advance care planning. We describe end-of-life care preferences and acute care and hospice use in the last 6 months of life for persons enrolled in a comprehensive dementia care management program.
Observational, retrospective cohort.
Urban, academic medical center.
A total of 322 persons enrolled in dementia care management after July 1, 2012, who died before July 1, 2016.
Dementia care comanagement model using nurse practitioners partnered with primary care providers and community organizations to provide comprehensive dementia care, including advance care planning.
Advance care preferences, use of Physician Orders for Life Sustaining Treatment (POLST), hospice enrollment, and hospitalizations and emergency department (ED) visits in the last 6 months of life obtained from electronic health record data.
Nearly all decedents (99.7%, N = 321) had a goals-of-care conversation documented (median = 3 conversations; interquartile range = 2-4 conversations), and 64% had advance care preferences recorded. Among those with recorded preferences, 88% indicated do not resuscitate, 48% limited medical interventions, and 35% chose comfort-focused care. Most patients (89%) specified limited artificial nutrition, including withholding feeding tubes. Over half (54%) had no hospitalizations or ED visits in the last 6 months of life, and intensive care unit stays were rare (5% of decedents). Overall, 69% died on hospice. Decedents who had completed a POLST were more likely to die in hospice care (74% vs 62%; P = .03) and die at home (70% vs 59%; P = .04).
Enrollees in a comprehensive dementia care comanagement program had high engagement in advance care planning, high rates of hospice use, and low acute care utilization near the end of life. Wider implementation of such programs may improve end-of-life care for persons with dementia. J Am Geriatr Soc 67:443-448, 2019.
背景/目的：尽管阿尔茨海默病和其他痴呆症是危及生命的疾病，但只有少数此类患者或其代理决策者参与了预先护理计划。我们描述了参与综合痴呆症护理管理计划的患者在生命的最后 6 个月中的临终关怀偏好以及急性护理和临终关怀的使用情况。
观察性、回顾性队列研究。
城市，学术医疗中心。
共有 322 名于 2012 年 7 月 1 日后参与痴呆症护理管理的患者，他们在 2016 年 7 月 1 日前死亡。
痴呆症共同管理模式采用护士从业者与初级保健提供者和社区组织合作，提供全面的痴呆症护理，包括预先护理计划。
从电子健康记录数据中获得生命维持治疗医生指令（POLST）、临终关怀入院和住院以及生命最后 6 个月内急诊就诊的预先护理偏好。
几乎所有死者（99.7%，N=321）的目标护理对话都有记录（中位数=3 次对话；四分位间距=2-4 次对话），并且 64%的人都有预先护理偏好记录。在有记录的偏好的患者中，88%的人表示不复苏，48%的人限制医疗干预，35%的人选择以舒适为重点的护理。大多数患者（89%）指定限制人工营养，包括停止喂养管。超过一半（54%）的患者在生命的最后 6 个月内没有住院或急诊就诊，重症监护病房的入住率很低（5%的死者）。总体而言，69%的患者在临终关怀中死亡。完成 POLST 的死者更有可能在临终关怀护理中死亡（74%比 62%；P=0.03），并且更有可能在家中死亡（70%比 59%；P=0.04）。
参与综合痴呆症共同护理管理计划的患者在预先护理计划方面的参与度很高，临终关怀的使用率很高，并且在生命的最后 6 个月内急性护理的利用率很低。更广泛地实施此类计划可能会改善痴呆症患者的临终关怀。美国老年医学会杂志 67:443-448，2019 年。
