Dalmau-Bueno Albert, Saura-Lazaro Anna, Busquets Josep Ma, Bullich-Marín Ingrid, García-Altés Anna
Catalan Health System Observatory, Agency for Health Quality and Assessment (AQuAS), Barcelona, Spain.
Catalan Institute of Oncology, Barcelona, Spain.
BMJ Support Palliat Care. 2021 Mar 22;12(e3):e337-44. doi: 10.1136/bmjspcare-2020-002851.
Advance directives (ADs) have been legally regulated to promote autonomy over health decisions among patients who later lose decision-making capacity.
To analyse the differences in clinical practice at end of life among people who had completed an AD versus those who had not.
Retrospective case-control study (1:2), matched by age, sex, year, cause of death and region of residence. The data sources used were the ADs registry, central registry of insured persons, hospital discharge, pharmacy and billing databases, and the mortality registry. Conditional logistic regression models (crude and adjusted by socioeconomic level) were performed. The outcome variable was the frequency of medical procedures performed during the last year of life.
1723 people with ADs who died in Catalonia during 2014-2015 were matched with 3446 dead controls (without ADs). Thoracentesis was the procedure with the greatest reduction among women with an AD (adjusted OR (OR) 0.54, 95% CI: 0.32 to 0.89) in conjunction with artificial nutrition (OR 0.54, 95% CI: 0.31 to 0.95). Intubation was the procedure with the greatest reduction (OR 0.56, 95% CI: 0.33 to 0.94) among men. Slight differences could be seen in the case of cancer deaths. There were no relevant differences when adjusting by socioeconomic level.
ADs are an effective tool to adjust the realisation of some procedures at end of life. These results can help better plan for the treatment of patients with ADs, as well as increase the awareness among clinical personnel, families and the general population.
预先医疗指示（ADs）已受到法律规范，以促进丧失决策能力患者在健康决策方面的自主权。
分析已完成预先医疗指示者与未完成者在生命末期临床实践中的差异。
回顾性病例对照研究（1:2），按年龄、性别、年份、死因和居住地区进行匹配。使用的数据源包括预先医疗指示登记册、被保险人中央登记册、医院出院记录、药房和计费数据库以及死亡率登记册。进行了条件逻辑回归模型（粗模型和按社会经济水平调整后的模型）分析。结果变量是生命最后一年进行的医疗程序的频率。
2014 - 2015年在加泰罗尼亚死亡的1723名有预先医疗指示者与3446名死亡对照者（无预先医疗指示）进行了匹配。胸腔穿刺术是有预先医疗指示的女性中减少最多的程序（调整后的比值比（OR）为0.54，95%置信区间：0.32至0.89），同时人工营养方面也是如此（OR为0.54，95%置信区间：0.31至0.95）。插管术是男性中减少最多的程序（OR为0.56，95%置信区间：0.33至0.94）。在癌症死亡病例中可看到细微差异。按社会经济水平调整后无显著差异。
预先医疗指示是调整生命末期某些程序实施的有效工具。这些结果有助于更好地规划有预先医疗指示患者的治疗，同时提高临床人员、家庭和公众的认识。
