Department of Psychiatry and Behavioral Sciences (W.E.R.), Memorial Sloan Kettering Cancer Center, New York, New York.
School of Nursing (S.I.), Oregon Health and Science University, Portland, Oregon.
J Pain Symptom Manage. 2023 Jan;65(1):e63-e78. doi: 10.1016/j.jpainsymman.2022.08.012. Epub 2022 Aug 24.
Advance care planning (ACP) intends to support person-centered medical decision-making by eliciting patient preferences. Research has not identified significant associations between ACP and goal-concordant end-of-life care, leading to justified scientific debate regarding ACP utility.
To delineate ACP's potential benefits and missed opportunities and identify an evidence-informed, clinically relevant path ahead for ACP in serious illness.
We conducted a narrative review merging the best available ACP empirical data, grey literature, and emergent scholarly discourse using a snowball search of PubMed, Medline, and Google Scholar (2000-2022). Findings were informed by our team's interprofessional clinical and research expertise in serious illness care.
Early ACP practices were largely tied to mandated document completion, potentially failing to capture the holistic preferences of patients and surrogates. ACP models focused on serious illness communication rather than documentation show promising patient and clinician results. Ideally, ACP would lead to goal-concordant care even amid the unpredictability of serious illness trajectories. But ACP might also provide a false sense of security that patients' wishes will be honored and revisited at end-of-life. An iterative, 'building block' framework to integrate ACP throughout serious illness is provided alongside clinical practice, research, and policy recommendations.
We advocate a balanced approach to ACP, recognizing empirical deficits while acknowledging potential benefits and ethical imperatives (e.g., fostering clinician-patient trust and shared decision-making). We support prioritizing patient/surrogate-centered outcomes with more robust measures to account for interpersonal clinician-patient variables that likely inform ACP efficacy and may better evaluate information gleaned during serious illness encounters.
预先医疗照护计划（ACP）旨在通过引出患者的偏好来支持以患者为中心的医疗决策。研究尚未发现 ACP 与目标一致的临终关怀之间存在显著关联，这导致了对 ACP 效用的合理科学辩论。
阐明 ACP 的潜在益处和错失的机会，并为严重疾病中的 ACP 确定一条循证的、具有临床相关性的前进道路。
我们通过对 PubMed、Medline 和 Google Scholar 进行滚雪球式搜索（2000-2022 年），合并了最佳可用的 ACP 实证数据、灰色文献和新兴学术论述，进行了叙述性综述。我们团队在严重疾病护理方面的跨专业临床和研究专业知识为研究结果提供了信息。
早期的 ACP 实践主要与强制性文件完成相关联，可能未能捕捉到患者和代理人的整体偏好。专注于严重疾病沟通而不是文件记录的 ACP 模式显示出对患者和临床医生有希望的结果。理想情况下，即使在严重疾病轨迹的不可预测性中，ACP 也会导致目标一致的护理。但是，ACP 也可能给人一种虚假的安全感，即患者的意愿将在生命末期得到尊重和重新考虑。提供了一个迭代的“构建块”框架，以在严重疾病期间整合 ACP，同时提供临床实践、研究和政策建议。
我们提倡对 ACP 采取平衡的方法，承认实证缺陷，同时承认潜在的益处和道德义务（例如，促进医患信任和共同决策）。我们支持优先考虑以患者/代理人为中心的结果，并采用更有力的措施来衡量可能影响 ACP 效果的人际临床医生-患者变量，并可能更好地评估在严重疾病期间获得的信息。
