Teno J, Lynn J, Wenger N, Phillips R S, Murphy D P, Connors A F, Desbiens N, Fulkerson W, Bellamy P, Knaus W A
Center to Improve Care of the Dying, George Washington University, Washington, DC 20037, USA.
J Am Geriatr Soc. 1997 Apr;45(4):500-7. doi: 10.1111/j.1532-5415.1997.tb05178.x.
To assess the effectiveness of written advance directives (ADs) in the care of seriously ill, hospitalized patients. In particular, to conduct an assessment after ADs were promoted by the Patient Self-Determination Act (PSDA) and enhanced by the effort to improve decision-making in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT), focusing upon the impact of ADs on decision-making about resuscitation.
Observational cohort study conducted for 2 years before (PRE) and for 2 years after (POST) the PSDA, with a randomized, controlled trial of an additional intervention to improve decision-making after PSDA (POST+SUPPORT).
Five teaching hospitals in the United States.
A total of 9105 seriously ill patients treated in five teaching hospitals.
The PSDA mandated patient education about ADs at hospital entry and documentation of ADs in the medical record. The SUPPORT intervention, in addition, provided a nurse to facilitate communication among patients, surrogates, and physicians about preferences for and outcomes of treatment alternatives and, when clinically appropriate, to encourage completion and utilization of ADs.
Interviews were conducted with patients, surrogates, and attending physicians about awareness, completion, and impact of ADs. Medical records were reviewed for discussion about preferences concerning resuscitation, timing and writing of "Do Not Resuscitate" (DNR) orders, evidence of ADs, and the use or forgoing of resuscitation at the time of death.
In the three cohorts, PRE, POST, and POST+SUPPORT, average age was 63. One-quarter of patients died during the initial hospitalization, one-half were dead within 6 months, and one-half were unconscious for their last 3 days. Before the PSDA (PRE), 62% were familiar with a living will, and 21% had an AD. These rates were similar for the POST and POST+SUPPORT cohorts. Just 36 (6%) of these directives were mentioned in the medical records for PRE, but a stable 35% were documented for POST, and POST+SUPPORT had an increasing rate averaging 78% (P < .001). As previously reported for PRE patients, the POST patients with and without ADs had no significant differences in the rates of medical record documentation of discussions about resuscitation (33% vs 38%, POST without AD vs POST with AD), DNR orders among those who wanted to forgo resuscitation (54% vs 58%), and attempted resuscitations at death (17% vs 9%). The POST+SUPPORT patients had similar results, with no evidence that the intervention enhanced the effect of ADs on these three measures of resuscitation decision-making. Patients with ADs more often reported that preferences about resuscitation were discussed with a physician (e.g., for POST patients, 30% for those with no AD and 43% for those with an AD, P < .05). Only 12% of patients with ADs had talked with a physician when completing the AD. Only 42% reported ever having discussed the AD with their physician. By the second study week, only one in four physicians was aware of patients' ADs.
In these seriously ill patients, ADs did not substantially enhance physician-patient communication or decision-making about resuscitation. This lack of effect was not altered by the PSDA or by the enhanced efforts in SUPPORT, although these interventions each substantially increased documentation of existing ADs. Current practice patterns indicate that increasing the frequency of ADs is unlikely to be a substantial element in improving the care of seriously ill patients. Future work to improve decision-making should focus upon improving the current pattern of practice through better communication and more comprehensive advance care planning.
评估书面预立医疗指示（ADs）在重症住院患者护理中的有效性。特别是在《患者自主决定法案》（PSDA）推动并通过“了解治疗预后和风险的患者偏好及结果研究”（SUPPORT）中改善决策的努力得到加强之后，进行评估，重点关注ADs对复苏决策的影响。
在PSDA实施前2年（PRE）和实施后2年（POST）进行观察性队列研究，并对PSDA实施后（POST + SUPPORT）的一项额外改善决策的干预措施进行随机对照试验。
美国的五家教学医院。
五家教学医院共9105名重症患者。
PSDA要求在患者入院时对其进行关于ADs的教育，并在病历中记录ADs。此外，SUPPORT干预措施安排一名护士，以促进患者、代理人和医生之间就治疗方案的偏好和结果进行沟通，并在临床适当的时候鼓励完成并使用ADs。
就ADs的知晓情况、完成情况和影响对患者、代理人及主治医生进行访谈。查阅病历，了解关于复苏偏好的讨论、“不要复苏”（DNR）医嘱的下达时间和书写情况、ADs的证据以及死亡时复苏的使用或放弃情况。
在PRE、POST和POST + SUPPORT这三个队列中，平均年龄为63岁。四分之一的患者在初次住院期间死亡，一半在6个月内死亡，一半在生命的最后3天处于昏迷状态。在PSDA实施前（PRE），62%的患者熟悉生前遗嘱，21%有ADs。POST和POST + SUPPORT队列的这些比例相似。在PRE队列中，病历中仅提及36份（6%）此类指示，但POST队列中记录比例稳定在35%，POST + SUPPORT队列的记录比例平均上升至78%（P < 0.001）。如之前对PRE患者的报道，有ADs和没有ADs的POST患者在关于复苏的讨论的病历记录比例（无ADs的POST患者为33%，有ADs的POST患者为38%）、想要放弃复苏的患者中下达DNR医嘱的比例（54%对58%）以及死亡时尝试复苏的比例（17%对9%）方面没有显著差异。POST + SUPPORT队列的结果相似，没有证据表明该干预措施增强了ADs对这三项复苏决策指标的影响。有ADs的患者更常报告与医生讨论过关于复苏的偏好（例如，对于POST患者，无ADs的患者为30%，有ADs的患者为43%，P < 0.05）。只有12%有ADs的患者在完成AD时与医生交谈过。只有42%的患者报告曾与医生讨论过ADs。到研究第二周时，只有四分之一的医生知晓患者的ADs。
在这些重症患者中，ADs并未显著增强医患沟通或关于复苏的决策。PSDA或SUPPORT中的强化措施并未改变这种无效状况，尽管这些干预措施各自都大幅增加了现有ADs的记录。当前的实践模式表明，增加ADs的频率不太可能成为改善重症患者护理的重要因素。未来改善决策的工作应侧重于通过更好的沟通和更全面的预立医疗照护计划来改进当前的实践模式。
