Nassikas Nicholas J, Baird Grayson L, Duffy Christine M
Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Warren Alpert Medical School, Brown University, Providence, RI, USA.
Lifespan Biostatistics Core, Rhode Island Hospital, Providence, RI, USA.
Am J Hosp Palliat Care. 2020 Mar;37(3):185-190. doi: 10.1177/1049909119872757. Epub 2019 Sep 2.
Two-thirds of chronically ill patients do not have an advance directive. The primary aim of this study was to develop an intervention to increase the documentation of advance directives in elderly adults in an internal medicine resident primary care clinic. The secondary aims were to improve resident confidence in discussing advance care planning and increase the number of discussions.
The study was a pre- and postintervention study. The study intervention was a 30-minute educational session on advance care planning. Study participants were patients aged 65 years and older who were seen in an internal medicine residency primary care clinic over a 6-month period and internal medicine residents. Clinic encounters were reviewed for the presence of advance care planning discussions before and after the intervention. Resident confidence was measured on a Likert scale.
Two hundred ninety-five eligible patients were seen in the clinic from January 1, 2017, to June 30, 2017, and included in the analysis performed between 2017 and 2018. The mean number of documented advance care planning discussions increased from 2.24 (95% confidence interval [CI]: 1.0-4.9) during the preintervention period to 8.94 (95% CI: 5.94-13.24]) during the postintervention period ( = .0011). Following the intervention, residents overall reported increased confidence in discussing advance care planning.
A relatively modest intervention to increase advance care planning discussions is feasible in an internal medicine primary care clinic and can improve the confidence of residents with end-of-life discussion.
三分之二的慢性病患者没有预先医疗指示。本研究的主要目的是制定一项干预措施，以增加内科住院医师初级保健诊所中老年患者预先医疗指示的记录。次要目的是提高住院医师在讨论预先护理计划方面的信心，并增加讨论次数。
该研究为干预前后对照研究。研究干预措施是一场关于预先护理计划的30分钟教育课程。研究参与者为65岁及以上的患者，这些患者在6个月内于内科住院医师初级保健诊所就诊，以及内科住院医师。对干预前后的临床诊疗记录进行审查，以查看是否存在预先护理计划讨论。通过李克特量表测量住院医师的信心。
2017年1月1日至2017年6月30日期间，诊所共接待了295名符合条件的患者，并纳入2017年至2018年进行的分析。记录的预先护理计划讨论的平均次数从干预前的2.24次（95%置信区间[CI]：1.0 - 4.9）增加到干预后的8.94次（95%CI：5.94 - 13.24）（P = .0011）。干预后，住院医师总体报告在讨论预先护理计划方面的信心有所增强。
在内科初级保健诊所，一项相对适度的增加预先护理计划讨论的干预措施是可行的，并且可以提高住院医师进行临终讨论的信心。
