Division of Hematology & Oncology, Department of Medicine, University of Florida College of Medicine, Gainesville, FL, USA.
Division of Hematology/Oncology, Mayo Clinic, Jacksonville, FL, USA.
J Palliat Care. 2021 Oct;36(4):211-218. doi: 10.1177/08258597211001153. Epub 2021 Mar 12.
Advance directives are legal documents that include living wills and durable health care power of attorney documents. They are critical components of care for seriously ill patients which are designed to be implemented when a patient is terminally ill and incapacitated. We sought to evaluate potential reasons for why advance directives were not appropriately implemented, by reviewing the electronic health record (EHR) in patients with terminal cancer.
A retrospective analysis of the EHR of 500 cancer patients from 1/1/2013 to 12/31/2016 was performed. Data points were manually collected and entered in a central database.
Of the 500 patients, 160 (32%) had an advance directive (AD). The most common clinical terminology used by physicians indicating a terminal diagnosis was progressive (36.6%) and palliative (31%). The most common clinical terminology indicating incapacity was altered mental status (25.6%), and not oriented (14%). 34 (6.8%) patients met all criteria of having a terminal diagnosis, a documented AD, and were deemed incapacitated. Of these patients who met all of these data points, their ADs were implemented on average 1.7 days (SD: 4.4 days) after which they should have been. This resulted in a total of 58 days of additional care provided.
This study provided insight on to how ADs are managed in day to day practice in the hospital. From our analysis it appears that physicians are able to identify when a patient is terminal, however, it is typically later than it should have been recognized. Further studies should be performed focusing on harnessing the power of the EHR and providing physicians formative and evaluative feedback of practice patterns to ensure that ADs are honored when appropriate.
预立医嘱是包括生前遗嘱和持久医疗保健授权书在内的法律文件。它们是重病患者护理的重要组成部分，旨在患者生命垂危且丧失能力时实施。我们试图通过审查患有绝症的患者的电子健康记录 (EHR)，来评估预立医嘱未得到适当实施的潜在原因。
对 2013 年 1 月 1 日至 2016 年 12 月 31 日的 500 名癌症患者的 EHR 进行了回顾性分析。手动收集数据点并输入中央数据库。
在 500 名患者中，有 160 名（32%）有预立医嘱 (AD)。医生表示终末期诊断的最常见临床术语是进展性（36.6%）和姑息性（31%）。表示无能力的最常见临床术语是精神状态改变（25.6%）和定向障碍（14%）。34 名（6.8%）患者符合所有终末期诊断、有记录的 AD 和无能力的标准。在这些符合所有数据点的患者中，他们的 AD 平均在应该实施后的 1.7 天（标准差：4.4 天）后实施。这总共导致额外提供了 58 天的护理。
这项研究提供了有关 AD 在医院日常实践中如何管理的见解。从我们的分析来看，医生似乎能够确定患者何时处于终末期，但通常比应该认识到的要晚。应该进行进一步的研究，重点是利用 EHR 的力量，并为医生提供实践模式的形成性和评估性反馈，以确保在适当的时候尊重 AD。
