Department of Family Practice, University of British Columbia, 713-828 West 10th Avenue, Vancouver, BC, V5Z 1M9, Canada.
HomeViVE Program, Vancouver General Hospital, Vancouver, BC, Canada.
BMC Geriatr. 2021 Feb 2;21(1):97. doi: 10.1186/s12877-021-02035-x.
Advance care planning (ACP) is a process that enables individuals to describe, in advance, the kind of health care they would want in the future. There is evidence that ACP reduces hospital-based interventions, especially at the end of life. ACP for frail older adults is especially important as this population is more likely to use hospital services but less likely to benefit from resource intensive care. Our study goal was to evaluate whether an approach to ACP developed for frail older adults, known as the Palliative and Therapeutic Harmonization or PATH, demonstrated an improvement in ACP.
The PATH approach was adapted to a primary care service for homebound older adults in Vancouver, Canada. This retrospective chart review collected surrogate measures related to ACP from 200 randomly selected patients enrolled in the service at baseline (prior to June 22, 2017), and 114 consecutive patients admitted to the program after implementation of the PATH ACP initiative (October 1, 2017 to May 1, 2018). We compared the following surrogate markers of ACP before and after implementation of the PATH model, chart documentation of: frailty stage, substitute decision-maker, resuscitation decision, and hospitalization decision. A composite ACP documentation score that ascribed one point for each of the above four measures (range 0 to 4) was also compared. For those with documented resuscitation and hospitalization decisions, the study examined patient/ substitute decision-maker expressed preferences for do-not-resuscitate and do-not-hospitalize, before and after implementation.
We found the following changes in ACP-related documentation before and after implementation: frailty stage (27.0% versus 74.6%, p < .0001); substitute decision-maker (63.5% versus 71.9%, p = 0.128); resuscitation decision documented (79.5% versus 67.5%, p = 0.018); and hospitalization decision documented (61.5% versus 100.0%, p < .0001); mean (standard deviation) composite ACP documentation score (2.32 (1.16) versus 3.14 (1.11), p < .0001). The adjusted odds ratios (95% confidence intervals) for an expressed preference of do-not-resuscitate and do-not-hospitalize after implementation were 0.87 (0.35, 2.15) and 3.14 (1.78, 5.55), respectively.
Results suggest partial success in implementing the PATH approach to ACP in home-based primary care. Key contextual enablers and barriers are important considerations for successful implementation.
预先医疗指示（advance care planning，ACP）是一种使个人能够预先描述他们未来所需医疗保健的过程。有证据表明，ACP 可以减少医院干预，尤其是在生命末期。对于体弱的老年人进行 ACP 尤其重要，因为这一人群更有可能使用医院服务，但从资源密集型护理中获益的可能性较小。我们的研究目的是评估为体弱老年人开发的 ACP 方法，即缓和医疗与治疗协调（Palliative and Therapeutic Harmonization or PATH），是否能提高 ACP 水平。
PATH 方法适用于加拿大温哥华的一项面向居家体弱老年人的初级保健服务。这项回顾性图表审查从该服务中随机选择的 200 名患者基线（2017 年 6 月 22 日前）和 114 名连续入院的患者中收集与 ACP 相关的替代指标，这些患者是在 PATH ACP 计划实施后（2017 年 10 月 1 日至 2018 年 5 月 1 日）入院的。我们比较了实施 PATH 模型前后以下 ACP 替代指标的变化：图表记录的虚弱阶段、替代决策人、复苏决策和住院决策。还比较了每个患者上述四项措施的总和（范围为 0 至 4）的 ACP 记录得分。对于有记录的复苏和住院决策的患者/替代决策人，在实施前后，研究还检查了他们对不复苏和不住院的表达意愿。
我们发现，在实施前后，ACP 相关记录有以下变化：虚弱阶段（27.0% 对 74.6%，p<0.0001）；替代决策人（63.5% 对 71.9%，p=0.128）；记录的复苏决策（79.5% 对 67.5%，p=0.018）；以及记录的住院决策（61.5% 对 100.0%，p<0.0001）；平均（标准差）ACP 记录得分（2.32（1.16）对 3.14（1.11），p<0.0001）。实施后表达不复苏和不住院意愿的调整优势比（95%置信区间）分别为 0.87（0.35，2.15）和 3.14（1.78，5.55）。
结果表明，在居家初级保健中实施 PATH 方法进行 ACP 取得了部分成功。关键的背景促成因素和障碍是成功实施的重要考虑因素。
