Nishikawa Yuri, Hiroyama Natsuko, Fukahori Hiroki, Ota Erika, Mizuno Atsushi, Miyashita Mitsunori, Yoneoka Daisuke, Kwong Joey Sw
Tokyo Medical and Dental University, Department of System Management in Nursing Graduate School of Health Care Sciences, Tokyo, Japan.
Keio University, Faculty of Nursing and Medical Care, Fujisawa, Japan.
Cochrane Database Syst Rev. 2020 Feb 27;2(2):CD013022. doi: 10.1002/14651858.CD013022.pub2.
People with heart failure report various symptoms and show a trajectory of periodic exacerbations and recoveries, where each exacerbation event may lead to death. Current clinical practice guidelines indicate the importance of discussing future care strategies with people with heart failure. Advance care planning (ACP) is the process of discussing an individual's future care plan according to their values and preferences, and involves the person with heart failure, their family members or surrogate decision-makers, and healthcare providers. Although it is shown that ACP may improve discussion about end-of-life care and documentation of an individual's preferences, the effects of ACP for people with heart failure are uncertain.
To assess the effects of advance care planning (ACP) in people with heart failure compared to usual care strategies that do not have any components promoting ACP.
We searched CENTRAL, MEDLINE, Embase, CINAHL, Social Work Abstracts, and two clinical trials registers in October 2019. We checked the reference lists of included studies. There were no restrictions on language or publication status.
We included randomised controlled trials (RCTs) that compared ACP with usual care in people with heart failure. Trials could have parallel group, cluster-randomised, or cross-over designs. We included interventions that implemented ACP, such as discussing and considering values, wishes, life goals, and preferences for future medical care. The study participants comprised adults (18 years of age or older) with heart failure.
Two review authors independently extracted outcome data from the included studies, and assessed their risk of bias. We contacted trial authors when we needed to obtain missing information.
We included nine RCTs (1242 participants and 426 surrogate decision-makers) in this review. The meta-analysis included seven studies (876 participants). Participants' mean ages ranged from 62 to 82 years, and 53% to 100% of the studies' participants were men. All included studies took place in the US or the UK. Only one study reported concordance between participants' preferences and end-of-life care, and it enrolled people with heart failure or renal disease. Owing to one study with small sample size, the effects of ACP on concordance between participants' preferences and end-of-life care were uncertain (risk ratio (RR) 1.19, 95% confidence interval (CI) 0.91 to 1.55; participants = 110; studies = 1; very low-quality evidence). It corresponded to an assumed risk of 625 per 1000 participants receiving usual care and a corresponding risk of 744 per 1000 (95% CI 569 to 969) for ACP. There was no evidence of a difference in quality of life between groups (standardised mean difference (SMD) 0.06, 95% CI -0.26 to 0.38; participants = 156; studies = 3; low-quality evidence). However, one study, which was not included in the meta-analysis, showed that the quality of life score improved by 14.86 points in the ACP group compared with 11.80 points in the usual care group. Completion of documentation by medical staff regarding discussions with participants about ACP processes may have increased (RR 1.68. 95% CI 1.23 to 2.29; participants = 92; studies = 2; low-quality evidence). This corresponded to an assumed risk of 489 per 1000 participants with usual care and a corresponding risk of 822 per 1000 (95% CI 602 to 1000) for ACP. One study, which was not included in the meta-analysis, also showed that ACP helped to improve documentation of the ACP process (hazard ratio (HR) 2.87, 95% CI 1.09 to 7.59; participants = 232). Three studies reported that implementation of ACP led to an improvement of participants' depression (SMD -0.58, 95% CI -0.82 to -0.34; participants = 278; studies = 3; low-quality evidence). We were uncertain about the effects of ACP on the quality of communication when compared to the usual care group (MD -0.40, 95% CI -1.61 to 0.81; participants = 9; studies = 1; very low-quality evidence). We also noted an increase in all-cause mortality in the ACP group (RR 1.32, 95% CI 1.04 to 1.67; participants = 795; studies = 5). The studies did not report participants' satisfaction with care/treatment and caregivers' satisfaction with care/treatment.
AUTHORS' CONCLUSIONS: ACP may help to increase documentation by medical staff regarding discussions with participants about ACP processes, and may improve an individual's depression. However, the quality of the evidence about these outcomes was low. The quality of the evidence for each outcome was low to very low due to the small number of studies and participants included in this review. Additionally, the follow-up periods and types of ACP intervention were varied. Therefore, further studies are needed to explore the effects of ACP that consider these differences carefully.
心力衰竭患者会出现各种症状，并呈现出周期性加重和缓解的病程，每次加重事件都可能导致死亡。当前的临床实践指南指出，与心力衰竭患者讨论未来护理策略非常重要。预先护理计划（ACP）是根据个人价值观和偏好讨论其未来护理计划的过程，涉及心力衰竭患者、其家庭成员或替代决策者以及医疗保健提供者。尽管有研究表明，ACP可能会改善关于临终护理的讨论以及记录个人偏好，但ACP对心力衰竭患者的影响尚不确定。
评估预先护理计划（ACP）相较于未包含任何促进ACP内容的常规护理策略，对心力衰竭患者的影响。
我们于2019年10月检索了Cochrane系统评价数据库（CENTRAL）、医学期刊数据库（MEDLINE）、荷兰医学文摘数据库（Embase）、护理学与健康领域数据库（CINAHL）、社会工作摘要数据库以及两个临床试验注册库。我们还查阅了纳入研究的参考文献列表。对语言或发表状态没有限制。
我们纳入了比较ACP与心力衰竭患者常规护理的随机对照试验（RCT）。试验可以采用平行组、整群随机或交叉设计。我们纳入了实施ACP的干预措施，例如讨论和考虑价值观、愿望、生活目标以及对未来医疗护理的偏好。研究参与者包括18岁及以上的成年心力衰竭患者。
两位综述作者独立从纳入研究中提取结局数据，并评估其偏倚风险。当需要获取缺失信息时，我们会联系试验作者。
本综述纳入了9项RCT（1242名参与者和426名替代决策者）。荟萃分析纳入了7项研究（876名参与者）。参与者的平均年龄在62至82岁之间，各研究中男性参与者的比例为53%至100%。所有纳入研究均在美国或英国进行。只有一项研究报告了参与者偏好与临终护理之间的一致性，该研究纳入了心力衰竭或肾病患者。由于一项研究样本量较小，ACP对参与者偏好与临终护理之间一致性的影响尚不确定（风险比（RR）为1.19，95%置信区间（CI）为0.91至1.55；参与者 = 110；研究 = 1；极低质量证据）。这相当于每1000名接受常规护理的参与者中假定有625例风险，而ACP对应的风险为每1000例中有744例（95% CI为569至969）。没有证据表明两组之间生活质量存在差异（标准化均数差（SMD）为0.06，95% CI为 -0.26至0.38；参与者 = 156；研究 = 3；低质量证据）。然而，一项未纳入荟萃分析的研究表明，ACP组的生活质量得分提高了14.86分，而常规护理组提高了11.80分。医务人员完成关于与参与者讨论ACP过程的记录可能有所增加（RR为1.68，95% CI为1.23至2.29；参与者 = 92；研究 = 2；低质量证据）。这相当于每1000名接受常规护理的参与者中假定有489例风险，而ACP对应的风险为每1000例中有822例（95% CI为602至1000）。一项未纳入荟萃分析的研究还表明，ACP有助于改善ACP过程的记录（风险比（HR）为2.87，95% CI为1.09至7.59；参与者 = 232）。三项研究报告称，实施ACP可改善参与者的抑郁状况（SMD为 -0.58，95% CI为 -0.82至 -0.34；参与者 = 278；研究 = 3；低质量证据）。与常规护理组相比，我们不确定ACP对沟通质量的影响（均差（MD）为 -0.40，95% CI为 -1.61至0.81；参与者 = 9；研究 = 1；极低质量证据）。我们还注意到ACP组全因死亡率有所增加（RR为1.32，95% CI为1.04至1.67；参与者 = 795；研究 = 5）。这些研究未报告参与者对护理/治疗的满意度以及护理人员对护理/治疗的满意度。
ACP可能有助于增加医务人员关于与参与者讨论ACP过程的记录，并可能改善个体的抑郁状况。然而，关于这些结局的证据质量较低。由于本综述纳入的研究和参与者数量较少，每个结局的证据质量为低到极低。此外，随访期和ACP干预类型各不相同。因此，需要进一步研究以仔细考虑这些差异后探讨ACP的影响。
