Haines Krista L, Nguyen Benjamin P, Antonescu Ioana, Freeman Jennifer, Cox Christopher, Krishnamoorthy Vijay, Kawano Brad, Agarwal Suresh
Division of Trauma and Critical Care and Acute Care Surgery, Department of Surgery, 22957Duke University Medical Center, Durham, NC, USA.
The Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, 22957Duke University Medical Center, Durham, NC, USA.
Am Surg. 2023 Jan;89(1):88-97. doi: 10.1177/00031348211011115. Epub 2021 Apr 20.
Advanced directives (ADs) provide a framework from which families may understand patient's wishes. However, end-of-life planning may not be prioritized by everyone. This analysis aimed to determine what populations have ADs and how they affected trauma outcomes.
Adult trauma patients recorded in the American College of Surgeons Trauma Quality Improvement Program (TQIP) from 2013-2015 were included. The primary outcome was presence of an AD. Secondary outcomes included mortality, length of stay (LOS), mechanical ventilation, ICU admission/LOS, withdrawal of life-sustaining measures, and discharge disposition. Multivariable logistic regression models were developed for outcomes.
44 705 patients were included in the analyses. Advanced directives were present in 1.79% of patients. The average age for patients with ADs was 77.8 ± 10.7. African American (odds ratio (OR) .53, confidence intervals [CI] .36-.79) and Asian (OR .22, CI .05-.91) patients were less likely to have ADs. Conversely, Medicaid (OR 1.70, CI 1.06-2.73) and Medicare (OR 1.65, CI 1.25-2.17) patients were more likely to have ADs as compared to those with private insurance. The presence of ADs was associated with increased hospital mortality (OR 2.84, CI 2.19-3.70), increased transition to comfort measures (OR 2.87, CI 2.08-3.95), and shorter LOS (CO -.74, CI -1.26-.22). Patients with ADs had an increased odds of hospice care (OR 4.24, CI 3.18-5.64).
Advanced directives at admission are uncommon, particularly among African Americans and Asians. The presence of ADs was associated with increased mortality, use of mechanical ventilation, admission to the ICU, withdrawal of life-sustaining measures, and hospice. Future research should target expansion of ADs among minority populations to alleviate disparities in end-of-life treatment.
预立医疗指示（ADs）为家属了解患者意愿提供了一个框架。然而，并非所有人都将临终规划列为优先事项。本分析旨在确定哪些人群拥有预立医疗指示以及它们如何影响创伤治疗结果。
纳入2013年至2015年美国外科医师学会创伤质量改进项目（TQIP）中记录的成年创伤患者。主要结局是是否存在预立医疗指示。次要结局包括死亡率、住院时间（LOS）、机械通气、入住重症监护病房/在重症监护病房的住院时间、撤销维持生命措施以及出院处置。针对各结局建立多变量逻辑回归模型。
44705例患者纳入分析。1.79%的患者有预立医疗指示。有预立医疗指示的患者平均年龄为77.8±10.7岁。非裔美国人（优势比[OR]0.53，置信区间[CI]0.36 - 0.79）和亚洲人（OR 0.22，CI 0.05 - 0.91）拥有预立医疗指示的可能性较小。相反，与拥有私人保险的患者相比，医疗补助计划（OR 1.70，CI 1.06 - 2.73）和医疗保险（OR 1.65，CI 1.25 - 2.17）的患者更有可能拥有预立医疗指示。预立医疗指示的存在与医院死亡率增加（OR 2.84，CI 2.19 - 3.70）、向舒适措施的转变增加（OR 2.87，CI 2.08 - 3.95）以及住院时间缩短（CO -0.74，CI -1.26 - -0.22）相关。有预立医疗指示的患者接受临终关怀的几率增加（OR 4.24，CI 3.18 - 5.64）。
入院时的预立医疗指示并不常见，尤其是在非裔美国人和亚洲人中。预立医疗指示的存在与死亡率增加、机械通气的使用、入住重症监护病房、撤销维持生命措施以及临终关怀相关。未来的研究应致力于在少数族裔人群中扩大预立医疗指示的使用，以减轻临终治疗中的差异。
