Aller Ashley, Hauser Karen, Pedell Leon, Martinez Francisco, Lin Amy
Department of Hematology/Oncology, The Permanente Medical Group, San Francisco, CA, USA.
Department of Internal Medicine, Kaiser Permanente Northern California, San Francisco, CA, USA.
Am J Hosp Palliat Care. 2024 Jun;41(6):634-640. doi: 10.1177/10499091231188715. Epub 2023 Aug 18.
Advanced cancer patients benefit less from aggressive therapies and more from goal-directed palliative management. Early and clearly documented goals-of-care discussions, including end-of-life decision making, are essential in this patient population. Integrated healthcare systems are comprehensive care models associated with improved quality of care and lower mortality compared to other healthcare models. The role of advance care planning within our system is understudied. Patients 18 years and older with a diagnosis of advanced-stage cancer were identified over a 6-month period. Expert panel review was performed to evaluate medical appropriateness of the selected diagnostic workup and management. The role and extent of care planning was reviewed in association with the clinical context. In a cohort of 82 patients, evidence-based and individualized appropriateness of medical management was found to be consistent for all patients. Eighty-two percent of patients elected for oncologic-based treatment, 5% pursued active surveillance, and 11% did not receive treatment. Seventy-three percent of patients were referred to palliative care. Fifty-six percent of patients had a full goals-of-care conversation documented; yet only 9% of goals-of-care conversations were documented by an oncologist. Prognosis was documented fully for only 22% of patients. At the end of the study period, 43 patients were deceased (52%), further indicating the critical importance of documentation. Within our integrated health system, we found consistent guideline- and patient-directed diagnosis and management, along with frequent integration of palliative care services. Goals-of-care conversation and prognosis documentation, especially by the oncologist, remains an area of needed improvement.
晚期癌症患者从积极治疗中获益较少，而从目标导向的姑息治疗中获益更多。对于这类患者群体而言，早期且有明确记录的医疗照护目标讨论，包括临终决策，至关重要。与其他医疗模式相比，综合医疗系统是一种全面的照护模式，与改善医疗质量和降低死亡率相关。我们系统中预先照护计划的作用尚未得到充分研究。在6个月的时间里，确定了18岁及以上诊断为晚期癌症的患者。进行了专家小组审查，以评估所选诊断检查和管理的医疗适宜性。结合临床背景对照护计划的作用和范围进行了审查。在一组82名患者中，发现所有患者的医疗管理在循证和个体化适宜性方面是一致的。82%的患者选择了基于肿瘤学的治疗，5%的患者进行了主动监测，11%的患者未接受治疗。73%的患者被转介至姑息治疗。56%的患者有完整记录的医疗照护目标对话；然而，只有9%的医疗照护目标对话由肿瘤学家记录。仅22%的患者有完整的预后记录。在研究期结束时，43名患者死亡（52%），这进一步表明了记录的至关重要性。在我们的综合医疗系统中，我们发现了一致的、以指南和患者为导向的诊断和管理，以及姑息治疗服务的频繁整合。医疗照护目标对话和预后记录，尤其是由肿瘤学家进行的记录，仍然是需要改进的领域。
