Nolan M T, Bruder M
Nursing Administration Department, The Johns Hopkins Hospital, Baltimore, Md., USA.
Nurs Outlook. 1997 Sep-Oct;45(5):204-8. doi: 10.1016/s0029-6554(97)90066-x.
Much of the patient education about advance directives described in the literature involves explaining the purpose of advance directives to patients and guiding them through the process of issuing a directive. However, well over half of the subjects in this study claimed to know enough about the directives to issue one, and almost all subjects expressed a preference for issuing directives when healthy. Although health care agencies that wish to adhere to the PSDA must continue to ask all patients if they have issued an advance directive, aggressive patient education programs that press hospitalized patients to consider issuing an advance directive may be perceived by patients as coercive and uncaring. Patient education may be more likely to achieve the goals of the PSDA if it is provided before hospitalization and if patients are encouraged to discuss their care preferences with family members who would be in a position to speak for them at the end of life. Further study of the few patients who choose to issue an advance directive would be informative. When and why they chose to issue the directive should be explored. Patients who report issuing an advance directive but do not provide their physician or hospital with a copy of the directive upon admission should also be studied to determine if this represents a desire not to activate the directive during the current admission or simply confusion about the disposition of this document. Finally, most studies of advance directives have been cross-sectional. Longitudinal study of patients who issue advance directives are needed to determine the effectiveness of these documents in influencing the end-of-life treatment that patients receive.
文献中描述的许多关于预先指示的患者教育内容，都涉及向患者解释预先指示的目的，并指导他们完成发出指示的过程。然而，本研究中超过半数的受试者声称对指示了解得足够多，可以发出一份指示，并且几乎所有受试者都表示倾向于在健康时发出指示。尽管希望遵守《患者自主决定法案》（PSDA）的医疗机构必须继续询问所有患者是否已发出预先指示，但向住院患者施压以促使其考虑发出预先指示的积极患者教育项目，可能会被患者视为强制性的和冷漠的。如果在住院前提供患者教育，并且鼓励患者与在其生命末期能够为其代言的家庭成员讨论他们的护理偏好，那么患者教育可能更有可能实现PSDA的目标。对少数选择发出预先指示的患者进行进一步研究将很有意义。应该探究他们何时以及为何选择发出指示。对于那些报告已发出预先指示但入院时未向其医生或医院提供指示副本的患者，也应该进行研究，以确定这是表示在本次住院期间不想激活该指示，还是仅仅对该文件的处置感到困惑。最后，大多数关于预先指示的研究都是横断面研究。需要对发出预先指示的患者进行纵向研究，以确定这些文件在影响患者接受的临终治疗方面的有效性。
