Mallery Laurie, Shetty Nabha, Moorhouse Paige, Miller Ashley Paige, von Maltzahn Maia, Buckler Melissa, MacLeod Tanya, Stewart Samuel A, Krueger-Naug Anne Marie
Department of Medicine, Faculty of Medicine, Dalhousie University, Halifax, NS B3H 4R2, Canada.
Nova Scotia Health Authority, Halifax, NS B3H 3A7, Canada.
J Clin Med. 2022 Mar 19;11(6):1710. doi: 10.3390/jcm11061710.
Goals of care discussions typically focus on decision maker preference and underemphasize prognosis and outcomes related to frailty, resulting in poorly informed decisions. Our objective was to determine whether navigated care planning with nursing home residents or their decision makers changed care plans during the first wave of the COVID-19 pandemic. The MED-LTC virtual consultation service, led by internal medicine specialists, conducted care planning conversations that balanced information-giving/physician guidance with resident autonomy. Consultation included (1) the assessment of co-morbidities, frailty, health trajectory, and capacity; (2) in-depth discussion with decision makers about health status and expected outcomes; and (3) co-development of a care plan. Non-parametric tests and logistic regression determined the significance and factors associated with a change in care plan. Sixty-three residents received virtual consultations to review care goals. Consultation resulted in less aggressive care decisions for 52 residents (83%), while 10 (16%) remained the same. One resident escalated their care plan after a mistaken diagnosis of dementia was corrected. Pre-consultation, 50 residents would have accepted intubation compared to 9 post-consultation. The de-escalation of care plans was associated with dementia, COVID-19 positive status, and advanced frailty. We conclude that during the COVID-19 pandemic, a specialist-led consultation service for frail nursing home residents significantly influenced decisions towards less aggressive care.
照护目标讨论通常侧重于决策者的偏好，而对与衰弱相关的预后和结果重视不足，导致决策缺乏充分信息。我们的目标是确定在新冠疫情第一波期间，为养老院居民或其决策者提供的导航式照护规划是否会改变照护计划。由内科专家主导的MED-LTC虚拟咨询服务开展了照护规划对话，在提供信息/医生指导与居民自主性之间取得平衡。咨询内容包括：（1）评估合并症、衰弱、健康轨迹和能力；（2）与决策者深入讨论健康状况和预期结果；（3）共同制定照护计划。非参数检验和逻辑回归确定了与照护计划改变相关的显著性和因素。63名居民接受了虚拟咨询以审查照护目标。咨询后，52名居民（83%）的照护决策变得不那么激进，而10名居民（16%）的决策保持不变。一名居民在痴呆症误诊被纠正后提高了其照护计划。咨询前，50名居民会接受插管，咨询后这一数字为9名。照护计划的降级与痴呆症、新冠病毒检测呈阳性状态和严重衰弱有关。我们得出结论，在新冠疫情期间，为衰弱的养老院居民提供的由专家主导的咨询服务显著影响了决策，使其倾向于采取不那么激进的照护措施。
