Intensive Care Department, University Hospital Geelong, Barwon Health, Geelong, Victoria, Australia.
School of Medicine, Deakin University, Geelong, Victoria, Australia.
Intern Med J. 2024 Jul;54(7):1197-1204. doi: 10.1111/imj.16381. Epub 2024 Mar 23.
Patients with a life-limiting illness (LLI) requiring hospitalisation have a high likelihood of deterioration and 12-month mortality. To avoid non-aligned care, we need to understand our patients' goals and values.
To describe the association between the implementation of a shared decision-making (SDM) programme and documentation of goals of care (GoC) for hospitalised patients with LLI.
A prospective longitudinal interventional study of patients admitted to acute general medicine wards in an Australian tertiary hospital over 5 years was conducted. A SDM programme with a new GoC form, communication training and clinical support was implemented. The primary outcome was the proportion of patients with a documented person-centred GoC discussion (PCD). Clinical outcomes included hospital utilisation and 90-day mortality.
1343 patients were included. The proportion of patients with PCDs increased from 0% to 35.4% (adjusted odds ratio (aOR), 2.38; 95% confidence interval (CI), 2.01-2.82; P < 0.001). During this time, median hospital length of stay decreased from 8 days (interquartile range (IQR), 4-14) to 6 days (IQR, 3-11) (adjusted estimate effect, -0.38; 95% CI, -0.64 to -0.11; P = 0.005) and rapid response team activation from 28% to 13% (aOR, 0.87; 95% CI, 0.78-0.97; P value = 0.01). Documented treatment preference of high-dependency unit care decreased from 39.7% to 24.4% (aOR, 0.81; 95% CI, 0.73-0.89; P value < 0.001), and ward-based care increased from 31.9% to 55.1% (aOR, 1.24; 95% CI, 1.14-1.36; P value < 0.001).
The implementation of a SDM programme was associated with increased documentation of person-centred GoC, changed patient treatment preference to lower intensity care and reduced hospital utilisation.
患有危及生命的疾病（LLI）并需要住院的患者极有可能病情恶化和在 12 个月内死亡。为了避免护理方向不一致，我们需要了解患者的目标和价值观。
描述实施共享决策（SDM）计划与记录患有危及生命的疾病的住院患者的护理目标（GoC）之间的关联。
对澳大利亚一家三级医院急性普通医学病房住院患者进行了为期 5 年的前瞻性纵向干预研究。实施了 SDM 计划，包括新的 GoC 表格、沟通培训和临床支持。主要结果是记录有以患者为中心的 GoC 讨论（PCD）的患者比例。临床结果包括住院利用和 90 天死亡率。
共纳入 1343 例患者。有 PCD 的患者比例从 0%增加到 35.4%（调整后的优势比（aOR），2.38；95%置信区间（CI），2.01-2.82；P<0.001）。在此期间，中位住院时间从 8 天（四分位距（IQR），4-14）减少到 6 天（IQR，3-11）（调整后估计效果，-0.38；95%CI，-0.64 至-0.11；P=0.005），快速反应团队的激活率从 28%降至 13%（aOR，0.87；95%CI，0.78-0.97；P 值=0.01）。记录的高依赖单位护理治疗偏好从 39.7%降至 24.4%（aOR，0.81；95%CI，0.73-0.89；P 值<0.001），而基于病房的护理从 31.9%增加到 55.1%（aOR，1.24；95%CI，1.14-1.36；P 值<0.001）。
实施 SDM 计划与记录以患者为中心的 GoC 增加、患者治疗偏好向低强度护理转变以及减少住院利用有关。
