Department of Health Sciences, Indiana University School of Health and Human Sciences, Indianapolis.
Indiana University Center for Aging Research, Regenstrief Institute, Inc, Indianapolis.
JAMA Netw Open. 2020 May 1;3(5):e205179. doi: 10.1001/jamanetworkopen.2020.5179.
An important aspect of high-quality care is ensuring that treatments are in alignment with patient or surrogate decision-maker goals. Treatment discordant with patient goals has been shown to increase medical costs and prolong end-of-life difficulties.
To evaluate discordance between surrogate decision-maker goals of care and medical orders and treatments provided to hospitalized, incapacitated older patients.
DESIGN, SETTING, AND PARTICIPANTS: This prospective cohort study included 363 patient-surrogate dyads. Patients were 65 years or older and faced at least 1 major medical decision in the medical and medical intensive care unit services in 3 tertiary care hospitals in an urban Midwestern area. Data were collected from April 27, 2012, through July 10, 2015, and analyzed from October 5, 2018, to December 5, 2019.
Each surrogate's preferred goal of care was determined via interview during initial hospitalization and 6 to 8 weeks after discharge. Surrogates were asked to select the goal of care for the patient from 3 options: comfort-focused care, life-sustaining treatment, or an intermediate option. To assess discordance, the preferred goal of care as determined by the surrogate was compared with data from medical record review outlining the medical treatment received during the target hospitalization.
A total of 363 dyads consisting of patients (223 women [61.4%]; mean [SD] age, 81.8 [8.3] years) and their surrogates (257 women [70.8%]; mean [SD] age, 58.3 [11.2] years) were included in the analysis. One hundred sixty-nine patients (46.6%) received at least 1 medical treatment discordant from their surrogate's identified goals of care. The most common type of discordance involved full-code orders for patients with a goal of comfort (n = 41) or an intermediate option (n = 93). More frequent in-person contact between surrogate and patient (adjusted odds ratio [AOR], 0.43; 95% CI, 0.23-0.82), patient residence in an institution (AOR, 0.44; 95% CI, 0.23-0.82), and surrogate-rated quality of communication (AOR, 0.98; 95% CI, 0.96-0.99) were associated with lower discordance. Surrogate marital status (AOR for single vs married, 1.92; 95% CI, 1.01-3.66), number of family members involved in decisions (AOR for ≥2 vs 0-1, 1.84; 95% CI, 1.05-3.21), and religious affiliation (AOR for none vs any, 4.87; 95% CI, 1.12-21.09) were associated with higher discordance.
This study found that discordance between surrogate goals of care and medical treatments for hospitalized, incapacitated patients was common. Communication quality is a modifiable factor associated with discordance that may be an avenue for future interventions.
高质量医疗的一个重要方面是确保治疗与患者或代理人的决策目标保持一致。已有研究表明，与患者目标不一致的治疗会增加医疗成本并延长临终困难。
评估住院、无行为能力的老年患者的代理人的护理目标与医疗医嘱和治疗之间的差异。
设计、地点和参与者：这项前瞻性队列研究纳入了 363 对患者-代理人。患者年龄在 65 岁及以上，在中西部市区的 3 家三级护理医院的医疗和医疗重症监护病房服务中面临至少 1 个主要医疗决策。数据收集于 2012 年 4 月 27 日至 2015 年 7 月 10 日，并于 2018 年 10 月 5 日至 2019 年 12 月 5 日进行分析。
每位代理人的首选护理目标通过患者在初始住院期间和出院后 6 至 8 周的访谈确定。代理人被要求从 3 个选项中为患者选择护理目标：以舒适为重点的护理、维持生命的治疗或中间选项。为了评估差异，将代理人确定的首选护理目标与医疗记录中概述的目标住院期间所接受的医疗治疗数据进行比较。
共纳入 363 对患者（223 名女性[61.4%]；平均[标准差]年龄，81.8[8.3]岁）及其代理人（257 名女性[70.8%]；平均[标准差]年龄，58.3[11.2]岁）进行了分析。169 名患者（46.6%）接受了至少 1 种与其代理人确定的护理目标不一致的医疗治疗。最常见的不一致类型涉及有舒适目标（n=41）或中间选项（n=93）的患者的全医嘱。代理人与患者之间更频繁的面对面接触（调整后的优势比[OR]，0.43；95%置信区间，0.23-0.82）、患者居住在机构（OR，0.44；95%置信区间，0.23-0.82）和代理人评定的沟通质量（OR，0.98；95%置信区间，0.96-0.99）与较低的不一致性相关。代理人的婚姻状况（单身与已婚的 OR，1.92；95%置信区间，1.01-3.66）、参与决策的家庭成员数量（≥2 人与 0-1 人的 OR，1.84；95%置信区间，1.05-3.21）和宗教信仰（无与任何的 OR，4.87；95%置信区间，1.12-21.09）与更高的不一致性相关。
本研究发现，住院、无行为能力的患者的代理人的护理目标与医疗治疗之间存在差异很常见。沟通质量是与差异相关的可改变因素，可能是未来干预措施的一个途径。
