Department of IQ Healthcare, Radboud University Medical Centre Nijmegen, the Netherlands.
Department of Primary and Community Care, Radboud University Medical Centre, Nijmegen, the Netherlands; Radboudumc Alzheimer Centre, Nijmegen, the Netherlands; Joachim en Anna, Centre for Specialized Geriatric Care, Nijmegen, the Netherlands.
J Am Med Dir Assoc. 2020 Jun;21(6):837-842.e4. doi: 10.1016/j.jamda.2019.09.010. Epub 2019 Nov 20.
Advance care planning (ACP) is seldom initiated with people with dementia (PWD) and mainly focuses on medical end-of-life decisions. We studied the effects of an educational intervention for general practitioners (GPs) aimed at initiating and optimizing ACP, with a focus on discussing medical and nonmedical preferences of future care.
A single-blinded cluster randomized controlled trial.
In 2016, 38 Dutch GPs (all from different practices) completed the study. They recruited 140 PWD, aged ≥65 years at any stage and with any type of dementia, from their practice.
Intervention group GPs were trained in ACP, including shared decision-making and role-playing exercises. Control group GPs provided usual care. The primary outcome was ACP initiation: the proportion of PWD that had at least 1 ACP conversation documented in their medical file. Key secondary outcomes were the number of medical (ie, resuscitation, hospital admission) and nonmedical (ie, activities, social contacts) preferences discussed. At the 6-month follow-up, subjects' medical records were analyzed using random effect logistics and linear models with correction for GP clustering.
38 GP clusters (19 intervention; 19 control) included 140 PWD (intervention 73; control 67). Four PWD (2.9%) dropped out on the primary and key secondary outcomes. After 6 months, intervention group GPs initiated ACP with 35 PWD (49.3%), and control group GPs initiated ACP with 9 PWD (13.9%) [odds ratio (OR) 1.99; P = .002]. Intervention group GPs discussed 0.8 more medical [95% confidence interval (CI) 0.3, 1.3; P = .003] and 1.5 more nonmedical (95% CI 0.8, 2.3; P < .001) preferences per person with dementia than control group GPs.
Our educational intervention increased ACP initiation, and the number of nonmedical and medical preferences discussed. This intervention has the potential to better align future care of PWD with their preferences but because of the short follow-up, the GPs' long-term adoption remains unknown.
预先医疗指示（ACP）很少在痴呆症患者（PWD）中启动，主要侧重于医疗临终决策。我们研究了针对全科医生（GP）的教育干预措施的效果，该措施旨在启动和优化 ACP，并侧重于讨论未来护理的医疗和非医疗偏好。
单盲群随机对照试验。
2016 年，38 名荷兰全科医生（均来自不同的诊所）完成了该研究。他们从诊所招募了 140 名年龄≥65 岁且患有任何类型痴呆症的 PWD。
干预组的全科医生接受了 ACP 培训，包括共同决策和角色扮演练习。对照组的全科医生提供常规护理。主要结局是 ACP 的启动：至少有 1 次 ACP 对话记录在患者病历中的 PWD 比例。关键次要结局是讨论的医疗（即复苏、住院）和非医疗（即活动、社会联系）偏好的数量。在 6 个月的随访中，使用随机效应逻辑和线性模型对受试者的病历进行分析，并针对 GP 聚类进行了校正。
38 个 GP 群组（19 个干预组；19 个对照组）包括 140 名 PWD（干预组 73 名；对照组 67 名）。有 4 名 PWD（2.9%）在主要和关键次要结局上退出。6 个月后，干预组的 GP 为 35 名 PWD 启动了 ACP（49.3%），对照组的 GP 为 9 名 PWD 启动了 ACP（13.9%）[优势比（OR）1.99；P=.002]。干预组 GP 每人讨论了 0.8 个更多的医疗[95%置信区间（CI）0.3，1.3；P=.003]和 1.5 个更多的非医疗[95% CI 0.8，2.3；P<.001]偏好。
我们的教育干预措施增加了 ACP 的启动以及讨论的非医疗和医疗偏好的数量。这种干预措施有可能更好地使 PWD 的未来护理与他们的偏好保持一致，但由于随访时间短，GP 的长期采用情况仍不清楚。
