School of Medicine, Duke University, Durham, North Carolina, USA.
Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California, USA.
J Am Geriatr Soc. 2021 Aug;69(8):2110-2121. doi: 10.1111/jgs.17230. Epub 2021 Jun 1.
BACKGROUND/OBJECTIVES: Advance care planning (ACP) rates are low in diverse, vulnerable older adults, yet little is known about the unique barriers they face and how these barriers impact ACP documentation rates.
Validated questionnaires listing patient, family/friend, and clinician/system-level ACP barriers and an open-ended question on ACP barriers.
Two San Francisco public/Department of Veterans Affairs hospitals.
One thousand two hundred and forty-one English and Spanish-speaking patients, aged 55 and older, with two or more chronic conditions.
The open-ended question on ACP barriers was analyzed using content analysis. We conducted chart review for prior ACP documentation. We used chi-square/Wilcoxon rank-sum tests and logistic regression to assess associations between ACP barriers and demographic characteristics/ACP documentation.
Participant mean age was 65 ± 7.4 years; they were 74% from racial/ethnic minority groups, 36% Spanish-speaking, and 36% with limited health literacy. A total of 26 barriers were identified (15 patient, 4 family/friend, 7 clinician/system-level), and 91% reported at least one ACP barrier (mean: 5.6 ± 4.0). The most common barriers were: (patient-level) discomfort thinking about ACP (60%), wanting to leave health decisions to "God" (44%); (family/friend-level) not wanting to burden friends/family (33%), assuming friends/family already knew their preferences (31%); (clinician/system-level) assuming doctors already knew their preferences (41%), and mistrust (37%). Compared with those with no barriers, participants with at least one reported barrier were more likely to be from a racial/ethnic minority group (76% vs 53%), Spanish-speaking (39% vs 6%), with fair-to-poor health (48% vs 34%), and limited health literacy (39% vs 9%) (p < 0.001 for all). Participants who reported barriers were less likely to have ACP documentation (adjusted odds ratio = 0.64, 95% confidence interval [0.42, 0.98]).
English- and Spanish-speaking older adults reported 26 unique barriers to ACP, with higher barriers among vulnerable populations, and barriers were associated with lower ACP documentation. Barriers must be considered when developing customized ACP interventions for diverse older adults.
背景/目的：在多样化、弱势的老年人群体中，预先医疗指示（ACP）的普及率较低，但人们对他们所面临的独特障碍知之甚少，也不清楚这些障碍如何影响 ACP 文件记录率。
使用列出患者、家属/朋友和临床医生/系统层面 ACP 障碍的有效问卷和一个关于 ACP 障碍的开放式问题。
旧金山两家公立/退伍军人事务部医院。
1241 名年龄在 55 岁及以上、患有两种或两种以上慢性疾病的讲英语和西班牙语的患者。
使用内容分析法分析 ACP 障碍的开放式问题。我们对之前的 ACP 文件记录进行了图表审查。我们使用卡方检验/Wilcoxon 秩和检验和逻辑回归来评估 ACP 障碍与人口统计学特征/ACP 文件记录之间的关联。
参与者的平均年龄为 65±7.4 岁；他们中 74%来自少数族裔群体，36%讲西班牙语，36%有有限的健康素养。共确定了 26 个障碍（15 个患者、4 个家庭/朋友、7 个临床医生/系统层面），91%的人报告了至少一个 ACP 障碍（平均 5.6±4.0）。最常见的障碍是：（患者层面）不愿意考虑 ACP（60%），希望将健康决策留给“上帝”（44%）；（家属/朋友层面）不想给朋友/家人带来负担（33%），假设朋友/家人已经知道他们的偏好（31%）；（临床医生/系统层面）假设医生已经知道他们的偏好（41%）和不信任（37%）。与没有障碍的参与者相比，报告至少有一个障碍的参与者更有可能来自少数族裔群体（76% vs. 53%），讲西班牙语（39% vs. 6%），健康状况一般或较差（48% vs. 34%），健康素养有限（39% vs. 9%）（p<0.001）。报告障碍的参与者更不可能有 ACP 文件记录（调整后的优势比=0.64，95%置信区间[0.42, 0.98]）。
讲英语和西班牙语的老年患者报告了 26 种独特的 ACP 障碍，弱势群体的障碍更高，障碍与较低的 ACP 文件记录率有关。在为多样化的老年患者制定定制的 ACP 干预措施时，必须考虑到这些障碍。
