Markson L J, Fanale J, Steel K, Kern D, Annas G
Geriatrics Section, Evans Memorial Department of Clinical Research, Boston, MA.
Arch Intern Med. 1994 Oct 24;154(20):2321-7.
Despite the potential benefits of advance directives, few patients complete them. This study examined whether barriers to advance decision making can be overcome via a combined educational and administrative intervention targeted at physicians.
The subjects consisted of all the internists (n = 6) at a primary care physician home care (HC) service and all the internists (n = 4) at a primary care nursing home (NH) service. Physicians were given a 5-week course on the law relating to advance directives. Administrative consent was obtained to permit physicians to spend additional time with patients to discuss advance directives. Physicians were asked to discuss advance directives with newly enrolled patients and to assist interested patients to complete directives. During the first 2 months of the trial, physicians did not approach any patients. Therefore, the study design was changed to include all active patients, and physicians received additional training that involved observing and leading discussions with their own patients.
Physicians approached 74 of 356 competent HC patients, of whom 48 (65%) completed directives. All 42 competent NH patients were approached, and 38 (90%) completed directives. Most patients who completed a directive chose relatives as proxies. Most directed that life-sustaining treatment be withheld in the event they were permanently unconscious (HC, 81%; NH, 92%). Other common choices were to decline long-term mechanical ventilation (HC, 58%; NH, 79%), long-term artificial nutrition (HC, 44%; NH, 79%), and cardiopulmonary resuscitation (HC, 27%; NH, 66%).
Physicians can overcome initial reluctance to integrate advance decision making into primary care provided to elderly patients. Teaching physicians about the law is not sufficient to change behavior; physicians also need practical experience discussing directives with patients. Our high patient response suggests that a physician-directed intervention is sufficient to achieve high rates of completing directives without additional, concomitant patient-directed intervention.
尽管预先指示有潜在益处，但很少有患者完成预先指示。本研究探讨了针对医生的教育与行政相结合的干预措施能否克服预先决策的障碍。
研究对象包括一家初级保健医生家庭护理（HC）服务机构的所有内科医生（n = 6）以及一家初级保健养老院（NH）服务机构的所有内科医生（n = 4）。为医生提供了为期5周的关于预先指示相关法律的课程。获得行政许可，允许医生花费额外时间与患者讨论预先指示。要求医生与新入院患者讨论预先指示，并协助有意愿的患者完成指示。在试验的前两个月，医生未接触任何患者。因此，研究设计改为纳入所有现患患者，医生接受了额外培训，包括观察并主导与自己患者的讨论。
在356名有行为能力的HC患者中，医生接触了74名，其中48名（65%）完成了指示。所有42名有行为能力的NH患者均被接触，38名（90%）完成了指示。大多数完成指示的患者选择亲属作为代理人。大多数患者指示，如果他们永久失去意识，应停止维持生命的治疗（HC，81%；NH，92%）。其他常见选择包括拒绝长期机械通气（HC，58%；NH, 79%）、长期人工营养（HC，44%；NH，79%）以及心肺复苏（HC，27%；NH，66%）。
医生能够克服最初不愿将预先决策纳入为老年患者提供的初级保健中的抵触情绪。仅向医生传授法律不足以改变行为；医生还需要与患者讨论指示的实践经验。我们较高的患者响应率表明，由医生主导的干预措施足以实现高比例的指示完成率，而无需额外的、同时进行的患者主导干预。
