一项使用医师助理和电子医患沟通工具来促进医院老年患者护理目标讨论的项目评估：一项试点研究。
Evaluation of a program using a physician assistant and an electronic patient-provider communication tool to facilitate discussions about goals of care in older adults in hospital: a pilot study.
作者信息
Monchis Monica, Martin Chris, DiDiodato Giulio
机构信息
Department of Critical Care Medicine (Monchis, Martin, DiDiodato), Royal Victoria Regional Health Centre, Barrie, Ont.; Department of Health Research Methods, Evidence and Impact (DiDiodato), McMaster University, Hamilton, Ont.
出版信息
CMAJ Open. 2020 Sep 14;8(3):E577-E584. doi: 10.9778/cmajo.20200022. Print 2020 Jul-Sep.
BACKGROUND
Many patients receive unwanted, low-value, high-intensity care at the end of life because of poor communication with health care providers. Our aim was to evaluate the feasibility of using a physician assistant and an electronic tool to facilitate discussions about goals of care.
METHOD
We conducted a pilot study for the intervention (physician assistant-led discussion using an electronic tool) from Apr. 1 to Aug. 31, 2019. Patients aged 79 years or older admitted to the Royal Victoria Hospital (Barrie, Ontario) with either (i) no documented resuscitation preferences or (ii) a request for life-sustaining treatments in the event of a life-threatening illness were eligible for the intervention. The goal of this study was to complete more than 30 interventions. The primary outcomes included the proportion of consenting eligible patients, the time required and the proportion of patients changing their resuscitation preferences.
RESULTS
A total of 763 patients met the inclusion criteria, with 337 eligible for the intervention. Of these, 49 cases were contacted for consent, and 37 interventions were completed (75.5%, 95% confidence interval [CI] 61.1%-86.6%). On average, the intervention required 50 minutes (standard deviation 21) to complete. Overall, 31 interventions resulted in a change in resuscitation preferences (83.7%, 95% CI 68.0%-93.8%), with 22 patients choosing to forgo any access to life-sustaining treatments in the event of a life-threatening illness (59.4%, 95% CI 42.1%-75.2%).
INTERPRETATION
In this pilot study, the intervention was completed in a minority of eligible patients and required substantial time; however, it led to many changes in resuscitation preferences. Before designing a study to evaluate its impact, the intervention needs to be revised to make it more efficient to administer.
背景
由于与医疗服务提供者沟通不畅，许多患者在生命末期接受了不必要的、低价值的、高强度的治疗。我们的目的是评估使用医师助理和电子工具来促进关于治疗目标讨论的可行性。
方法
我们于2019年4月1日至8月31日对该干预措施（使用电子工具由医师助理主导的讨论）进行了一项试点研究。入住皇家维多利亚医院（安大略省巴里市）的79岁及以上患者，若符合以下情况之一则有资格接受该干预：（i）没有记录在案的复苏偏好；或（ii）在危及生命的疾病发生时要求进行维持生命的治疗。本研究的目标是完成超过30次干预。主要结局包括同意参与的合格患者比例、所需时间以及改变复苏偏好的患者比例。
结果
共有763名患者符合纳入标准，其中337名有资格接受干预。在这些患者中，49例被联系以征求同意，37次干预得以完成（75.5%，95%置信区间[CI]61.1%-86.6%））。平均而言，完成干预需要50分钟（标准差21）。总体而言，31次干预导致复苏偏好发生改变（83.7%，95%CI68.0%-93.8%），其中22名患者选择在危及生命的疾病发生时放弃任何维持生命的治疗（59.4%，95%CI42.1%-75.2%）。
解读
在这项试点研究中，该干预措施仅在少数合格患者中得以完成且需要大量时间；然而，它导致了许多复苏偏好的改变。在设计一项研究来评估其影响之前，需要对该干预措施进行修订，以使其实施起来更高效。
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