COVID-19 大流行期间的高级医疗保健计划：医疗照护决策的上限及其对观察性数据的影响。
Advanced care planning during the COVID-19 pandemic: ceiling of care decisions and their implications for observational data.
机构信息
Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK.
Leeds Teaching Hospitals NHS Trust, Leeds, UK.
出版信息
BMC Palliat Care. 2021 Jan 11;20(1):10. doi: 10.1186/s12904-021-00711-8.
BACKGROUND
Observational studies investigating risk factors in coronavirus disease 2019 (COVID-19) have not considered the confounding effects of advanced care planning, such that a valid picture of risk for elderly, frail and multi-morbid patients is unknown. We aimed to report ceiling of care and cardiopulmonary resuscitation (CPR) decisions and their association with demographic and clinical characteristics as well as outcomes during the COVID-19 pandemic.
METHODS
Retrospective, observational study conducted between 5th March and 7th May 2020 of all hospitalised patients with COVID-19. Ceiling of care and CPR decisions were documented using the Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) process. Unadjusted and multivariable regression analyses were used to determine factors associated with ceiling of care decisions and death during hospitalisation.
RESULTS
A total of 485 patients were included, of whom 409 (84·3%) had a documented ceiling of care; level one for 208 (50·9%), level two for 75 (18·3%) and level three for 126 (30·8%). CPR decisions were documented for 451 (93·0%) of whom 336 (74·5%) were 'not for resuscitation'. Advanced age, frailty, White-European ethnicity, a diagnosis of any co-morbidity and receipt of cardiovascular medications were associated with ceiling of care decisions. In a multivariable model only advanced age (odds 0·89, 0·86-0·93 p < 0·001), frailty (odds 0·48, 0·38-0·60, p < 0·001) and the cumulative number of co-morbidities (odds 0·72, 0·52-1·0, p = 0·048) were independently associated. Death during hospitalisation was independently associated with age, frailty and requirement for level two or three care.
CONCLUSION
Ceiling of care decisions were made for the majority of patients during the COVID-19 pandemic, broadly in line with known predictors of poor outcomes in COVID-19, but with a focus on co-morbidities suggesting ICU admission might not be a reliable end-point for observational studies where advanced care planning is routine.
背景
研究 2019 年冠状病毒病（COVID-19）危险因素的观察性研究尚未考虑先进的护理计划的混杂影响，因此，对于老年、体弱和多病患者的风险尚不清楚。我们旨在报告在 COVID-19 大流行期间的护理上限和心肺复苏（CPR）决策及其与人口统计学和临床特征以及结局的关系。
方法
这是一项于 2020 年 3 月 5 日至 5 月 7 日期间对所有 COVID-19 住院患者进行的回顾性、观察性研究。使用推荐的紧急医疗和治疗概要计划（ReSPECT）流程记录护理上限和 CPR 决策。使用未调整和多变量回归分析来确定与护理上限决策和住院期间死亡相关的因素。
结果
共纳入 485 例患者，其中 409 例（84.3％）有记录的护理上限；一级为 208 例（50.9％），二级为 75 例（18.3％），三级为 126 例（30.8％）。451 例（93.0％）记录了 CPR 决策，其中 336 例（74.5％）为“不复苏”。高龄、虚弱、白种欧洲人种族、任何合并症的诊断和心血管药物的使用与护理上限决策相关。在多变量模型中，只有高龄（优势比 0.89，0.86-0.93，p<0.001）、虚弱（优势比 0.48，0.38-0.60，p<0.001）和合并症的累积数量（优势比 0.72，0.52-1.0，p=0.048）是独立相关的。住院期间死亡与年龄、虚弱和需要二级或三级护理独立相关。
结论
在 COVID-19 大流行期间，大多数患者都做出了护理上限决策，这与 COVID-19 不良结局的已知预测因素大致相符，但重点关注合并症表明，对于常规进行高级护理计划的观察性研究，入住 ICU 可能不是一个可靠的终点。
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