Berry S R, Singer P A
University of Toronto Joint Centre for Bioethics, and Department of Medical Oncology, Toronto-Sunnybrook Regional Cancer Centre, Ontario, Canada.
Cancer. 1998 Apr 15;82(8):1570-7.
Advance directives are an important part of end of life care, but current advance directive documents do not address the specific issues facing cancer patients. The authors' purpose was: 1) to develop a cancer specific advance directive, 2) determine whether oncology outpatients find this directive more acceptable than a generic advance directive, and 3) describe oncology outpatient preferences for life-sustaining treatment.
A cancer specific advance directive ("The Cancer Living Will"; the full text of the updated version is available at the University of Toronto Joint Centre for Bioethics website [URL: www.utoronto.ca/jcb]) was developed in four steps: 1) literature search, 2) key informant interviews, 3) focus groups, and 4) evaluation of face and content validity. Subsequently, 91 volunteer oncology patients were given copies of the cancer specific advance directive and the generic advance directive ("The University of Toronto Centre for Bioethics Living Will") from which it was adapted. Acceptability of the advance directive was measured by determining the participants' preferred directive. Participants recorded their treatment preferences in both the cancer specific and generic advance directives.
Of 60 patients who returned their questionnaires, 50 expressed a preference for the advance directive. Thirty-two patients (64%; 95% confidence interval (CI), 49-77%) preferred the disease specific Cancer Living Will and 18 patients (36%; 95% CI, 23-51%) preferred the generic Centre for Bioethics Living Will. Most participants who preferred the Cancer Living Will did so because it was more specific and relevant to their situation.
The authors have developed and evaluated a cancer specific advance directive that they believe can be recommended for clinical use with cancer patients.
预立医疗指示是临终关怀的重要组成部分，但目前的预立医疗指示文件并未涉及癌症患者面临的具体问题。作者的目的是：1）制定一份针对癌症的预立医疗指示；2）确定肿瘤门诊患者是否认为这份指示比通用的预立医疗指示更易接受；3）描述肿瘤门诊患者对维持生命治疗的偏好。
通过四个步骤制定了一份针对癌症的预立医疗指示（“癌症生前遗嘱”；更新版本的全文可在多伦多大学联合生物伦理中心网站获取[网址：www.utoronto.ca/jcb]）：1）文献检索；2）关键信息提供者访谈；3）焦点小组讨论；4）表面效度和内容效度评估。随后，向91名自愿参与的肿瘤患者提供了这份针对癌症的预立医疗指示以及改编自它的通用预立医疗指示（“多伦多大学联合生物伦理中心生前遗嘱”）。通过确定参与者偏好的指示来衡量预立医疗指示的可接受性。参与者在针对癌症的预立医疗指示和通用预立医疗指示中都记录了他们的治疗偏好。
在60名返回问卷的患者中，50名表达了对预立医疗指示的偏好。32名患者（64%；95%置信区间[CI]，49 - 77%）更喜欢针对特定疾病的“癌症生前遗嘱”，18名患者（36%；95%CI，23 - 51%）更喜欢通用的“联合生物伦理中心生前遗嘱”。大多数更喜欢“癌症生前遗嘱”的参与者这样做是因为它更具体且与他们的情况更相关。
作者制定并评估了一份针对癌症的预立医疗指示，他们认为该指示可推荐用于癌症患者的临床实践。
