Reilly B M, Wagner M, Ross J, Magnussen C R, Papa L, Ash J
St Mary's Hospital, Rochester, NY, USA.
Arch Intern Med. 1995 Nov 13;155(20):2202-6.
The wider use of written advance directives is popular but problematic. We have shown previously that acute hospitalization in the era of the Patient Self-Determination Act can facilitate directive discussions and documentation. We investigated whether a simple educational intervention following hospitalization would increase patients' execution of durable health care proxies.
We studied a consecutive series of patients (n = 162) recently discharged from the acute care medical service of a community hospital where they had been interviewed about advance directives. The intervention group was randomized to receive an educational brochure and encouragement to execute durable health care proxies. The primary outcome was the proportion of patients in each group with completed durable health care proxies on file in their primary physicians' offices.
Overall, only 20 (12.3%) of 162 patients had documented proxies, 17 of whom (85%) were 65 years of age or older, with no difference between the intervention and control groups (11 [13.3%] of 83 vs nine [11.4%] of 79, respectively). Subgroup analysis of elderly patients also revealed no intervention effect. Univariate analysis revealed three significant predictors of patients' proxy completion: patient age, whether patients had discussed directives in hospital with their physicians, and whether patients' physicians completed proxies for themselves. Multiple logistic regression analysis showed that these three variables interact to predict the probability of patients' executing proxies.
Simple educational interventions, like those mandated by the Patient Self-Determination Act, are unlikely to increase patients' completion of durable healthcare proxies. Multidimensional interventions that target both elderly patients and their personal physicians should be tested in the future. Discussion in hospital about advance directives can be a useful component of such efforts.
书面预立医疗指示的广泛使用很普遍但存在问题。我们之前已经表明，在《患者自我决定法案》时代，急性住院治疗有助于促进指示的讨论和记录。我们调查了住院后进行简单的教育干预是否会增加患者对医疗保健持久授权书的签署。
我们研究了一系列连续的患者（n = 162），这些患者最近从一家社区医院的急性护理医疗服务部门出院，在该医院他们接受了关于预立医疗指示的访谈。干预组被随机分配接受一份教育手册，并被鼓励签署医疗保健持久授权书。主要结局是每组中在其初级医生办公室存档有完整医疗保健持久授权书的患者比例。
总体而言，162名患者中只有20名（12.3%）有记录在案的授权书，其中17名（85%）年龄在65岁及以上，干预组和对照组之间无差异（分别为83名中的11名[13.3%]和79名中的9名[11.4%]）。老年患者的亚组分析也未显示干预效果。单因素分析显示了患者签署授权书的三个重要预测因素：患者年龄、患者是否在医院与医生讨论过指示以及患者的医生是否为自己签署了授权书。多因素逻辑回归分析表明，这三个变量相互作用以预测患者签署授权书的可能性。
像《患者自我决定法案》规定的那些简单教育干预不太可能增加患者对医疗保健持久授权书的签署。未来应测试针对老年患者及其私人医生的多维度干预措施。在医院中关于预立医疗指示的讨论可以是此类努力的一个有用组成部分。
