Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Langone Health, New York, New York, USA.
Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA.
J Pain Symptom Manage. 2019 Nov;58(5):857-863.e1. doi: 10.1016/j.jpainsymman.2019.07.015. Epub 2019 Jul 23.
Advance care planning (ACP) is difficult in the setting of a life-threatening trauma but may be equally important in this context, especially with increasing numbers of trauma victims being elderly or having multimorbidity.
Identify predictors of absent ACP documentation in the electronic health records of patients with underlying chronic illness who died of traumatic injury.
We used death records and electronic health records to identify decedents with chronic life-limiting illness who died of traumatic injury between 2010 and 2015 and to evaluate factors associated with documentation of living wills, durable powers of attorney, or physician orders for life-sustaining treatment.
Only 22% of decedents had ACP documentation at time of injury. Among those without preinjury ACP documentation, 4% completed ACP documentation after injury. In multipredictor analyses, patients were less likely to have ACP documentation at the time of injury if they were younger (P < 0.001), had fewer chronic illnesses (P = 0.002), and had fewer nonsurgical hospitalizations (P = 0.042) in the year before injury. Among patients without ACP documentation before injury, those with fewer postinjury nonsurgical hospitalizations were less likely to complete ACP documentation after injury (P = 0.019).
Our findings suggest that patient characteristics play an important role in the completion of ACP among patients with chronic life-limiting illness and who died from sudden severe injury. Interventions to improve ACP completion by patients with serious chronic conditions have the potential for increasing goal-concordant care in the event of traumatic injury.
在危及生命的创伤情况下，预先医疗指示（ACP）的制定较为困难，但这种情况下ACP 可能同样重要，尤其是越来越多的创伤患者为老年人或患有多种合并症。
确定患有潜在慢性疾病且因创伤性损伤而死亡的患者的电子健康记录中缺乏 ACP 记录的预测因素。
我们使用死亡记录和电子健康记录来确定在 2010 年至 2015 年期间因创伤性损伤而死亡且患有慢性生命终末期疾病的死者，并评估与生存意愿、持久授权书或医生对维持生命治疗的医嘱相关的因素。
只有 22%的死者在受伤时具有 ACP 记录。在没有预先 ACP 记录的死者中，有 4%在受伤后完成了 ACP 记录。在多因素分析中，如果患者在受伤时年龄较小（P<0.001）、患有较少的慢性疾病（P=0.002）和受伤前一年的非手术住院次数较少（P=0.042），则他们在受伤时更不可能有 ACP 记录。在受伤前没有 ACP 记录的患者中，受伤后非手术住院次数较少的患者更不可能在受伤后完成 ACP 记录（P=0.019）。
我们的研究结果表明，患者特征在患有慢性生命终末期疾病且因突发严重损伤而死亡的患者中 ACP 的完成中起着重要作用。针对患有严重慢性疾病的患者开展以提高 ACP 完成为目的的干预措施，有可能在发生创伤性损伤时增加与目标一致的护理。
