The Effect of a Comprehensive Dementia Care Management Program on End-of-Life Care.
The Effect of a Comprehensive Dementia Care Management Program on End-of-Life Care.
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DOI：
10.1111/jgs.15769
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发表时间：
2019-03
影响因子：
6.3
通讯作者：
Reuben, David B.
中科院分区：
文献类型：
--
作者：
Jennings, Lee A.;Turner, Maurice;Keebler, Chandra;Burton, Carl H.;Romero, Tahmineh;Wenger, Neil S.;Reuben, David B.
虽然阿尔茨海默氏病和其他痴呆症是限制生命的，但只有少数这些患者或他们的代理决策者参与预先护理计划。我们描述了参加综合性痴呆症护理管理计划的人在生命的最后6个月内的临终关怀偏好和急性护理和临终关怀的使用。观察性、回顾性队列城市、学术医疗中心322人在2012年7月1日之后参加痴呆症护理管理，他们在2016年7月1日之前死亡。痴呆症护理共同管理模式使用执业护士与初级保健提供者和社区组织合作提供全面的痴呆症护理，包括提前护理计划。从电子健康记录数据中获得的生命最后六个月的预先护理偏好、生命维持治疗医嘱（POLST）的使用、临终关怀登记以及住院和急诊科（艾德）访视。几乎所有死者（99.7%，N=321）都记录了护理目标对话（中位数3次对话，IQR [2，4]），64%记录了预先护理偏好。在有记录偏好的人中，88%表示不复苏，48%限制医疗干预，35%选择以舒适为中心的护理。大多数患者（89%）指定有限的人工营养，包括扣留饲管。超过一半（54%）的人在生命的最后六个月内没有住院或艾德就诊，重症监护病房的情况很少（占死亡人数的5%）。总的来说，69%的人死于临终关怀。完成POLST的死者更有可能在临终关怀中死亡（74% vs. 62%，p=0.03），并在家中死亡（70% vs. 59%，p=0.04）。参加综合性痴呆症护理共同管理计划的患者对提前护理计划的参与度高，临终关怀使用率高，接近生命末期的急性护理利用率低。更广泛地实施这些方案可能会改善痴呆症患者的临终关怀。
Although Alzheimer’s disease and other dementias are life-limiting, only a minority of these patients or their proxy decision-makers participate in advance care planning. We describe end-of-life care preferences and acute care and hospice use in the last 6 months of life for persons enrolled in a comprehensive dementia care management program. Observational, retrospective cohort Urban, academic medical center 322 persons enrolled in dementia care management after July 1, 2012 who died before July 1, 2016 Dementia care co-management model using nurse practitioners partnered with primary care providers and community organizations to provide comprehensive dementia care, including advance care planning. Advance care preferences, use of Physician Orders for Life Sustaining Treatment (POLST), hospice enrollment, and hospitalizations and emergency department (ED) visits in the last six months of life obtained from electronic health record data. Nearly all decedents (99.7%, N=321) had a goals-of-care conversation documented (median 3 conversations, IQR [2, 4]), and 64% had advance care preferences recorded. Among those with recorded preferences, 88% indicated do not resuscitate, 48% limited medical interventions, and 35% chose comfort-focused care. Most patients (89%) specified limited artificial nutrition, including withholding feeding tubes. Over half (54%) had no hospitalizations or ED visits in the last six months of life, and intensive care unit stays were rare (5% of decedents). Overall, 69% died on hospice. Decedents who had completed a POLST were more likely to die in hospice care (74% vs. 62%, p=0.03) and die at home (70% vs. 59%, p=0.04). Enrollees in a comprehensive dementia care co-management program had high engagement in advance care planning, high rates of hospice use, and low acute care utilization near the end of life. Wider implementation of such programs may improve end-of-life care for persons with dementia.
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