Lien Center for Palliative Care, Duke-NUS Medical School, Singapore.
Lien Center for Palliative Care, Duke-NUS Medical School, Singapore.
J Am Med Dir Assoc. 2021 Feb;22(2):349.e29-349.e34. doi: 10.1016/j.jamda.2020.05.030. Epub 2020 Jul 18.
Patient preference for place of death is an important component of advance care planning (ACP). If patients' preference for place of death changes over time, this questions the value of their documented preference. We aimed to assess the extent and correlates of change in preference for place of death over time among patients with symptoms of advanced heart failure.
We conducted a secondary analysis of data from a randomized controlled trial of a formal ACP program vs usual care.
We interviewed 282 patients aged 21 years old and above with heart failure and New York Heart Association Classification III and IV symptoms in Singapore. Analytic sample included 200 patients interviewed at least twice.
We assessed factors associated with patients' preference for place of death (home/institution/no preference) and change in their preference for place of death from previous time point (change toward home death/toward an institutional death/toward no preference/no change). These included patient demographics, quality of life (Kansas City Cardiomyopathy Questionnaire), and prognostic understanding.
In our study, 66% of patients with heart failure changed their preference for place of death at least once during the study period with no consistent pattern of change. Correct prognostic understanding at the time of survey reduced the relative risk of change in preference for place of death to home (relative risk ratio 0.49, 95% confidence interval 0.32, 0.76), whereas a higher quality of life score was associated with a lower relative risk of patients changing their preferred place of death to an institution (relative risk ratio 0.99, 95% confidence interval 0.97, 1.00) relative to no change in preference.
We provide evidence of instability in patients with heart failure preference for place of death, which suggests that ACP documents should be regularly re-evaluated.
患者对死亡地点的偏好是预先护理计划（ACP）的一个重要组成部分。如果患者对死亡地点的偏好随时间发生变化，那么这就质疑了他们记录的偏好的价值。我们旨在评估在有晚期心力衰竭症状的患者中，随时间推移对死亡地点的偏好发生变化的程度和相关因素。
我们对一项正式 ACP 计划与常规护理的随机对照试验数据进行了二次分析。
我们在新加坡对年龄在 21 岁及以上、心力衰竭并有纽约心脏协会分类 III 和 IV 症状的 282 名患者进行了访谈。分析样本包括至少两次接受访谈的 200 名患者。
我们评估了与患者对死亡地点的偏好（家庭/机构/无偏好）以及他们对死亡地点的偏好从上次的变化（向家庭死亡转变/向机构死亡转变/向无偏好转变/无变化）相关的因素。这些因素包括患者的人口统计学特征、生活质量（堪萨斯城心肌病问卷）和预后理解。
在我们的研究中，66%的心力衰竭患者在研究期间至少改变了一次他们对死亡地点的偏好，但没有一致的变化模式。在调查时正确理解预后可以降低对家庭死亡偏好变化的相对风险（相对风险比 0.49，95%置信区间 0.32，0.76），而较高的生活质量评分与患者将首选死亡地点改为机构的相对风险降低相关（相对风险比 0.99，95%置信区间 0.97，1.00），而不是偏好没有变化。
我们提供了心力衰竭患者对死亡地点的偏好不稳定的证据，这表明 ACP 文档应定期重新评估。
