Simpson Centre for Health Services Research, South West Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia.
School of Clinical Medicine, University of New South Wales, Sydney, New South Wales, Australia.
Intern Med J. 2024 Aug;54(8):1414-1417. doi: 10.1111/imj.16458.
The current fallback position for the elderly frail nearing the end of life (less than 12 months to live) is hospitalisation. There is a reluctance to use the term 'terminally ill' for this population, resulting in overtreatment, overdiagnosis and management that is not consistent with the wishes of people. This is the major contributor to the so-called hospital crisis, including decreased capacity of hospitals, reduced ability to conduct elective surgery, increased attendances at emergency departments and ambulance ramping. The authors recently conducted the largest randomised study, to their knowledge, attempting to inform specialist hospital medical teams about the terminally ill status of their admitted patients. This information did not influence their clinical decisions in any way. The authors discuss the reasons why this may have occurred, such as the current avoidance of discussing death and dying by society and the concentration of healthcare workers on actively managing the acute presenting problem and ignoring the underlying prognosis in the elderly frail. The authors discuss ways of improving the management of the elderly nearing the end of life, such as more detailed goals of care discussions using the concept of shared decision-making rather than simply completing Advanced Care Decision documents. Empowering people in this way could become the most important driver of people's health care.
当前，生命即将走到尽头（预计存活时间不足 12 个月）的体弱老年人的默认选择是住院治疗。由于不愿用“绝症”来描述这一人群，导致过度治疗、过度诊断和管理与患者的意愿不符。这是所谓的医院危机的主要原因，包括医院容量下降、择期手术能力降低、急诊科就诊人数增加和救护车等待时间延长。作者最近进行了他们所知的最大规模的随机研究，试图告知住院患者专科医疗团队其绝症患者的状况。但该信息并未以任何方式影响他们的临床决策。作者讨论了为什么会出现这种情况的原因，例如社会目前对死亡和濒死的回避，以及医疗保健工作者专注于积极管理急性发病问题，而忽略了老年体弱患者的潜在预后。作者讨论了改善即将走到生命尽头的老年人管理的方法，例如使用共同决策的概念而不是简单地完成预先医疗指示文件来进行更详细的护理目标讨论。以这种方式赋予人们权力可能成为推动人们获得医疗保健的最重要动力。
