Johnston S C, Pfeifer M P, McNutt R
Department of Internal Medicine, University of Kansas School of Medicine-Wichita, USA.
Arch Intern Med. 1995 May 22;155(10):1025-30. doi: 10.1001/archinte.155.10.1025.
Widely publicized court cases have focused national attention on the importance of advance directives. In spite of initiatives such as the Patient Self-Determination Act of 1991, fewer than 10% of Americans have prepared advance directives. One way to increase the preparation of advance directives may be to increase the frequency and quality of discussions about them between individual patients and their physicians. We performed a multicenter observational study to assess the opinions of primary care patients and physicians regarding these discussions.
This was a cross-sectional descriptive survey of randomly selected primary care patients and physicians in eight primary care internal medicine clinics in the eastern and midwestern United States. Quantitative questionnaires were used to elicit subjects' demographic characteristics, and their opinions regarding the timing, content, and location of discussions about advance directives.
The 883 subjects included 329 adult outpatients, 282 resident physicians, and 272 practicing physicians. Physician and patient response rates were 75% and 76%, respectively. Patients felt that the discussion should occur earlier than did the physicians: at an earlier age, earlier in the natural history of disease, and earlier in the patient-physician relationship. Most subjects agreed it was the physician's responsibility to initiate the discussion.
We defined a discrepancy between the preferences of primary care patients and physicians regarding the timing of the discussion about advance directives. We propose physician education regarding patient preferences as the most effective way to accomplish the goal of improving the frequency and quality of discussions about advance directives.
备受关注的法庭案件使全国都聚焦于预先指示的重要性。尽管有诸如1991年《患者自我决定法案》等举措，但准备预先指示的美国人不到10%。增加预先指示准备率的一种方法可能是增加个体患者与其医生之间关于预先指示讨论的频率和质量。我们进行了一项多中心观察性研究，以评估初级保健患者和医生对这些讨论的看法。
这是一项对美国东部和中西部8家初级保健内科诊所随机选取的初级保健患者和医生进行的横断面描述性调查。使用定量问卷来获取受试者的人口统计学特征，以及他们对预先指示讨论的时间、内容和地点的看法。
883名受试者包括329名成年门诊患者、282名住院医师和272名执业医师。医生和患者的回复率分别为75%和76%。患者认为讨论应比医生认为的时间更早进行：在更早的年龄、疾病自然史的更早阶段以及医患关系的更早阶段。大多数受试者同意由医生负责发起讨论。
我们发现初级保健患者和医生在关于预先指示讨论的时间偏好上存在差异。我们建议对医生进行关于患者偏好的教育，这是实现提高预先指示讨论频率和质量这一目标的最有效方法。
