家庭照护偏好记录可改善家庭初级保健中家庭成员的体验。
Family members' experience improves with care preference documentation in home based primary care.
机构信息
Department of Veterans Affairs, Rocky Mountain Regional VA Medical Center, Aurora, Colorado, USA.
University of Colorado School of Medicine, Aurora, Colorado, USA.
出版信息
J Am Geriatr Soc. 2021 Dec;69(12):3576-3583. doi: 10.1111/jgs.17410. Epub 2021 Aug 14.
BACKGROUND
The Veterans Health Administration (VA) implemented the comprehensive life-sustaining treatment (LST) Decisions Initiative to provide training and standardize documentation of goals of care and LST preferences for seriously ill Veterans to improve end-of-life (EOL) outcomes. LST documentation is expected for all Home-Based Primary Care (HBPC) Veterans because they are at high risk of hospitalization and mortality.
METHODS
A retrospective, cross-sectional analysis compared associations between Bereaved Family Survey (BFS) EOL care ratings and LST documentation. Participants were Veterans who died August 1, 2018 through September 30, 2019 in one of 55 VA HBPC programs. Regression modeling generated odds for key BFS outcomes. LST template completion rate was plotted by month to understand the interaction between time, LST completion rate, and EOL care family ratings.
RESULTS
LST preferences were documented for 39% of HBPC Veterans. Family members rated overall EOL care as excellent for 53% of Veterans but significant divergence in BFS ratings occurred during the last 7 months of the study with 60% of family members of LST completers rating care as excellent compared with 48% for Veterans lacking LST documentation (p = 0.003). The adjusted odds of rating overall care in the final month of life as excellent was higher among those with a completed LST template (1.64 95% CI 1.19, 2.26).
CONCLUSIONS
Higher rates of LST documentation were associated with more favorable ratings of EOL but not in initial months following implementation of the comprehensive initiative; however, LST documentation rates were lower than expected among HBPC Veterans. Following an initial period of implementation of a comprehensive national initiative to promote Veteran choice about care during serious illness, documented LST preferences were associated with better family ratings of EOL care. HBPC clinicians may improve the bereaved family experience by using LSDTI tools and training to elicit and document preferences.
背景
退伍军人健康管理局（VA）实施了全面维持生命治疗（LST）决策计划，为患有重病的退伍军人提供培训并规范目标护理和 LST 偏好的记录，以改善临终（EOL）结局。所有家庭为基础的初级保健（HBPC）退伍军人都需要进行 LST 记录，因为他们有住院和死亡的高风险。
方法
一项回顾性、横断面分析比较了临终关怀调查（BFS）EOL 护理评分与 LST 记录之间的关联。参与者是 2018 年 8 月 1 日至 2019 年 9 月 30 日期间在 55 个 VA HBPC 项目之一死亡的退伍军人。回归模型生成关键 BFS 结果的几率。通过每月绘制 LST 模板完成率图，了解时间、LST 完成率和 EOL 护理家庭评分之间的相互作用。
结果
HBPC 退伍军人中有 39%记录了 LST 偏好。家属对 53%退伍军人的 EOL 护理整体评分优异，但在研究的最后 7 个月，BFS 评分出现显著差异，60%接受 LST 治疗的退伍军人家属对护理的评分优异，而缺乏 LST 记录的退伍军人为 48%（p=0.003）。在生命的最后一个月，对整体护理的评分较高的退伍军人，其完成的 LST 模板的几率更高（1.64 95%CI 1.19，2.26）。
结论
LST 记录率较高与 EOL 评分较高相关，但在全面计划实施的最初几个月并非如此；然而，HBPC 退伍军人的 LST 记录率低于预期。在实施一项全面的国家计划以促进患有重病的退伍军人对护理选择的初始阶段之后，记录的 LST 偏好与家属对 EOL 护理的更好评分相关。HBPC 临床医生可以通过使用 LSDTI 工具和培训来引出和记录偏好，从而改善失去亲人的家庭体验。
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