Palliative Medicine, OhioHealth, Columbus, Ohio, USA.
Grant Medical Center, Columbus, Ohio, USA.
J Palliat Med. 2024 Jul;27(7):846-853. doi: 10.1089/jpm.2023.0380. Epub 2024 Feb 27.
Withdrawal of life-sustaining treatment (WLST) is a process with unique pressure for all involved. The use of an electronic order set can facilitate best care. To assess utilization of a WLST order set and time to inpatient death before and after optimization. A retrospective chart review for 12-month periods before and after enhancements to a WLST order set. Multicenter study within an American, not-for-profit health care system of inpatient decedents July 2017-June 2018 and April 2021-March 2022 with orders placed via WLST order set. Co-primary outcomes included order set utilization and time from activation of orders to patient death. Descriptive analyses featured demographics, palliative consultation, ordering clinician type/specialty, and COVID-19. A total of 1949 patients had orders placed via the WLST order set and died in-hospital. Compared with the 2017-2018 period, use increased 35.8% in 2021-2022. Time to death after release of orders was significantly longer for the 2021-2022 group (4.4 vs. 3.7 hours). Demographic details included nurse practitioners (39%) as most frequent WLST order set utilizer and palliative consultation in 46% of terminal hospitalizations. Among decedents with consultation, palliative clinicians were the WLST order set utilizer for 47% of cases (i.e., 21% of all WLST order set utilizations). The median time to death was significantly longer when orders were placed by a palliative clinician (4.5 hours) compared with nonpalliative specialists (3.9 hours). COVID-19 was a hospital diagnosis for 29% of decedents in the 2021-2022 group. In the emotionally and cognitively intense process that is WLST, an order set provides a modifiable panel of defaults. Our experience highlights the power in guiding primary palliative care for WLST in the hospital setting and suggests that advanced practice providers and nonpalliative clinicians, as primary utilizers, be integral in the design of a WLST order set.
停止生命维持治疗 (WLST) 是一个涉及所有相关人员的独特压力过程。电子医嘱集的使用可以促进最佳护理。评估 WLST 医嘱集的使用情况和优化前后住院患者的死亡时间。回顾性图表审查了 2017 年 7 月至 2018 年 6 月和 2021 年 4 月至 2022 年 3 月期间增强 WLST 医嘱集前后 12 个月的住院死亡患者。这是一个在美国非营利性医疗机构内进行的多中心研究，患者在 2017-2018 年和 2021-2022 年期间通过 WLST 医嘱集下达了医嘱。主要结局包括医嘱集的使用情况和从医嘱激活到患者死亡的时间。描述性分析包括人口统计学特征、姑息治疗咨询、开医嘱的临床医生类型/专业以及 COVID-19。共有 1949 名患者通过 WLST 医嘱集下达了医嘱并在院内死亡。与 2017-2018 年相比，2021-2022 年的使用率增加了 35.8%。2021-2022 年组释放医嘱后死亡的时间明显更长（4.4 小时比 3.7 小时）。人口统计学细节包括执业护士（39%）是最常使用 WLST 医嘱集的人群，46%的终末期住院患者接受了姑息治疗咨询。在接受咨询的死者中，姑息治疗临床医生是 WLST 医嘱集使用者，占病例的 47%（即所有 WLST 医嘱集使用者的 21%）。当医嘱由姑息治疗临床医生下达时，死亡的中位时间明显更长（4.5 小时），而非姑息治疗专家（3.9 小时）。在 2021-2022 年组中，29%的死者被诊断患有 COVID-19。在 WLST 这个情感和认知上都很紧张的过程中，医嘱集提供了一组可修改的默认值。我们的经验强调了在医院环境中指导 WLST 的主要姑息治疗的力量，并表明初级实践提供者和非姑息治疗临床医生作为主要使用者，在 WLST 医嘱集的设计中不可或缺。
