Division of Geriatrics, Department of Medicine, University of California, 4150 Clement Street, 306B, San Francisco, CA, 94121, USA.
Division of Geriatrics, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA.
J Gen Intern Med. 2020 Jul;35(7):1946-1953. doi: 10.1007/s11606-020-05644-1. Epub 2020 May 4.
Although hip fractures in older adults are associated with a high degree of mortality and disability, the use of advance care planning (ACP) in this population is unknown.
To determine the prevalence of ACP and need for surrogate decision-making prior to death in older adults with hip fracture and to identify factors associated with ACP.
Retrospective cohort study using Health and Retirement Study (HRS) interviews linked to Medicare fee-for-service claims data.
Six hundred six decedent participants aged 65 or older who sustained a hip fracture during HRS enrollment and had a proxy participate in the exit HRS survey.
Survey responses by proxies were used to determine ACP, defined by either advance directive completion or surrogate designation, and to assess decision-making at the end of life. Multivariate logistic regression was used to analyze correlates of ACP.
Prior to death, 54.9% of all participants had an advance directive and 68.9% had designated a surrogate decision-maker; however, 24.5% had no ACP. Of the total cohort, 32.5% required decisions to be made about treatment at the end of life and lacked capacity to make these decisions themselves. In this subset, 19.9% had no ACP. In all participants, ACP was less likely in non-white individuals (adjusted odds ratio (aOR) 0.14, 95% CI 0.06-0.31), those with less than a high school education (aOR 0.58, 95% CI 0.35-0.97), and those with a net worth below the median of the cohort (aOR 0.49, 95% CI 0.26-0.72). No clinical factors were found to be associated with ACP completion prior to death.
A considerable number of older adults with hip fracture required surrogate decision-making at the end of life, of whom one fifth had no ACP prior to death. Clinicians providing care for these patients are uniquely poised to address ACP.
尽管老年人髋部骨折与高死亡率和残疾率相关，但该人群中使用预先医疗指示（ACP）的情况尚不清楚。
确定髋部骨折老年患者在死亡前进行 ACP 及需要指定代理人的情况，并确定与 ACP 相关的因素。
使用健康与退休研究（HRS）访谈并与 Medicare 按服务收费数据相链接的回顾性队列研究。
在 HRS 登记期间发生髋部骨折且有代理人参与 HRS 退出调查的 606 名 65 岁或以上的死亡参与者。
代理人的调查应答用于确定 ACP，通过完成预先医疗指示或指定代理人来定义，并评估生命终末期的决策。多变量逻辑回归用于分析 ACP 的相关性。
在死亡前，所有参与者中有 54.9% 完成了预先医疗指示，68.9% 指定了代理人，但 24.5% 没有进行 ACP。在总队列中，32.5% 需要在生命终末期做出治疗决策，但他们自己无法做出这些决策。在这个亚组中，19.9% 没有进行 ACP。在所有参与者中，非白人（调整后比值比（aOR）0.14，95%可信区间（CI）0.06-0.31）、受教育程度低于高中（aOR 0.58，95%CI 0.35-0.97）和净资产低于队列中位数（aOR 0.49，95%CI 0.26-0.72）的个体进行 ACP 的可能性较低。没有发现临床因素与死亡前完成 ACP 相关。
相当数量的髋部骨折老年患者在生命终末期需要代理人决策，其中五分之一在死亡前没有进行 ACP。为这些患者提供护理的临床医生在解决 ACP 方面具有独特的优势。
