Association of Physician Orders for Life-Sustaining Treatment With ICU Admission Among Patients Hospitalized Near the End of Life
Association of Physician Orders for Life-Sustaining Treatment With ICU Admission Among Patients Hospitalized Near the End of Life
复制标题
DOI：
10.1001/jama.2019.22523
复制
发表时间：
2020-03-10
影响因子：
120.7
通讯作者：
Kross, Erin K.
中科院分区：
文献类型：
--
作者：
Lee, Robert Y.;Brumback, Lyndia C.;Kross, Erin K.
慢性病患者经常使用维持生命治疗医嘱（POLST）来记录治疗限制。目的评估POLST医疗干预顺序与生命末期住院患者入住重症监护室（ICU）的相关性。设计、设置和参与者回顾性队列研究，研究对象为2010年1月1日至2017年12月31日期间死亡的POLST和慢性疾病患者，死亡前在2家医院的学术卫生保健系统中住院6个月或更短时间。暴露于POLST医疗干预顺序（“仅舒适措施”vs“有限的额外干预”vs“全面治疗”）、年龄、人种/种族、教育、从POLST完成到入院的天数、癌症或痴呆病史以及因创伤性损伤入院。主要结局和测量主要结局是POLST顺序与生命最后一次住院期间ICU入院之间的关系;次要结局是接受4种维持生命治疗的复合治疗：机械通气、血管加压药、透析和心肺复苏。为了评估POLST不一致治疗相关因素，结局是在生命的最后一次住院期间，ICU入院与POLST医疗干预顺序相反。结果在1818例死亡者中（平均年龄70.8 [SD，14.7]岁; 41%为女性），401例（22%）仅接受POLST安慰措施，761例（42%）接受有限额外干预措施，656例（36%）接受全面治疗。31%（95% CI，26%-35%）的患者接受了仅舒适订单，46%（95% CI，42%-49%）的患者接受了有限干预订单，62%（95% CI，58%-66%）的患者接受了全面治疗订单。14%（95% CI，11%-17%）的仅安慰订单患者和20%（95% CI，17%-23%）的有限干预订单患者接受了一种或多种维持生命的治疗。与接受全面治疗POLST的患者相比，接受仅舒适和有限干预命令的患者入住ICU的可能性明显降低（仅舒适性：123/401 [31%] vs 406/656 [62%]，aRR，0.53 [95% CI，0.45-0.62];有限干预：349/761 [46%] vs 406/656 [62%]，aRR，0.79 [95% CI，0.71-0.87]）。在仅舒适和有限干预POLST的患者中，38%（95% CI，35%-40%）接受POLST不一致治疗。与非癌症患者相比，癌症患者接受POLST不一致护理的可能性显著降低（仅舒适性：41/181 [23%] vs 80/220 [36%]，aRR，0.60 [95% CI，0.43-0.85];有限干预：100/321 [31%] vs 215/440 [49%]，aRR，0.63 [95% CI，0.51-0.78]）。痴呆患者和仅接受舒适命令的患者接受POLST不一致护理的可能性显著低于非痴呆患者（23/111 [21%] vs 98/290 [34%]，aRR，0.44 [95%CI，0.29-0.67]）。因创伤性损伤入院的患者更有可能接受POLST不一致护理（仅舒适性：29/64 [45%] vs 92/337 [27%]，aRR，1.52 [95% CI，1.08-2.14];有限干预：51/91 [56%] vs 264/670 [39%]，aRR，1.36 [95% CI，1.09-1.68]）。在接受有限干预治疗的患者中，年龄较大与POLST不一致治疗较少显著相关（aRR，0.93/10年[95%CI，0.88-1.00]）。结论和相关性在POLST患者和死亡后6个月内住院的慢性生命限制性疾病患者中，与完全治疗POLST相比，治疗限制性POLST与ICU入院率降低显著相关。38%的治疗限制性POLST患者接受了可能与其POLST不一致的重症监护。评估生命维持治疗医嘱（POLST）和重症监护病房（ICU）入院之间的关联以及死亡前6个月或更短时间内住院的成人患者中POLST不一致重症监护的发生率和风险因素的数据。问题对于在生命末期住院的具有治疗限制性生命维持治疗医嘱（POLST）的患者，他们的住院治疗符合POLST规定限制的频率是多少？结果在这项回顾性队列研究中，1818例POLST死亡者在死亡后6个月内住院，重症监护病房（ICU）入院率因POLST医疗干预顺序而显着不同（31%的人表示“仅采取舒适措施”，46%的人表示“有限的额外干预”，62%的人表示“全面治疗”）。尽管许多治疗限制性POLST患者接受的治疗可能与其POLST不一致，但对于接近生命末期住院的患者，治疗限制性POLST与完全治疗POLST相比，ICU入院率显著降低。
Importance Patients with chronic illness frequently use Physician Orders for Life-Sustaining Treatment (POLST) to document treatment limitations. Objectives To evaluate the association between POLST order for medical interventions and intensive care unit (ICU) admission for patients hospitalized near the end of life. Design, Setting, and Participants Retrospective cohort study of patients with POLSTs and with chronic illness who died between January 1, 2010, and December 31, 2017, and were hospitalized 6 months or less before death in a 2-hospital academic health care system. Exposures POLST order for medical interventions ("comfort measures only" vs "limited additional interventions" vs "full treatment"), age, race/ethnicity, education, days from POLST completion to admission, histories of cancer or dementia, and admission for traumatic injury. Main Outcomes and Measures The primary outcome was the association between POLST order and ICU admission during the last hospitalization of life; the secondary outcome was receipt of a composite of 4 life-sustaining treatments: mechanical ventilation, vasopressors, dialysis, and cardiopulmonary resuscitation. For evaluating factors associated with POLST-discordant care, the outcome was ICU admission contrary to POLST order for medical interventions during the last hospitalization of life. Results Among 1818 decedents (mean age, 70.8 [SD, 14.7] years; 41% women), 401 (22%) had POLST orders for comfort measures only, 761 (42%) had orders for limited additional interventions, and 656 (36%) had orders for full treatment. ICU admissions occurred in 31% (95% CI, 26%-35%) of patients with comfort-only orders, 46% (95% CI, 42%-49%) with limited-interventions orders, and 62% (95% CI, 58%-66%) with full-treatment orders. One or more life-sustaining treatments were delivered to 14% (95% CI, 11%-17%) of patients with comfort-only orders and to 20% (95% CI, 17%-23%) of patients with limited-interventions orders. Compared with patients with full-treatment POLSTs, those with comfort-only and limited-interventions orders were significantly less likely to receive ICU admission (comfort only: 123/401 [31%] vs 406/656 [62%], aRR, 0.53 [95% CI, 0.45-0.62]; limited interventions: 349/761 [46%] vs 406/656 [62%], aRR, 0.79 [95% CI, 0.71-0.87]). Across patients with comfort-only and limited-interventions POLSTs, 38% (95% CI, 35%-40%) received POLST-discordant care. Patients with cancer were significantly less likely to receive POLST-discordant care than those without cancer (comfort only: 41/181 [23%] vs 80/220 [36%], aRR, 0.60 [95% CI, 0.43-0.85]; limited interventions: 100/321 [31%] vs 215/440 [49%], aRR, 0.63 [95% CI, 0.51-0.78]). Patients with dementia and comfort-only orders were significantly less likely to receive POLST-discordant care than those without dementia (23/111 [21%] vs 98/290 [34%], aRR, 0.44 [95% CI, 0.29-0.67]). Patients admitted for traumatic injury were significantly more likely to receive POLST-discordant care (comfort only: 29/64 [45%] vs 92/337 [27%], aRR, 1.52 [95% CI, 1.08-2.14]; limited interventions: 51/91 [56%] vs 264/670 [39%], aRR, 1.36 [95% CI, 1.09-1.68]). In patients with limited-interventions orders, older age was significantly associated with less POLST-discordant care (aRR, 0.93 per 10 years [95% CI, 0.88-1.00]). Conclusions and Relevance Among patients with POLSTs and with chronic life-limiting illness who were hospitalized within 6 months of death, treatment-limiting POLSTs were significantly associated with lower rates of ICU admission compared with full-treatment POLSTs.However, 38% of patients with treatment-limiting POLSTs received intensive care that was potentially discordant with their POLST.This cohort study uses electronic health record (EHR) data to evaluate the association between Physician Orders for Life-Sustaining Treatment (POLST) and intensive care unit (ICU) admission and the incidence of and risk factors for POLST-discordant intensive care among adult patients hospitalized 6 months or less before death.Question For patients with treatment-limiting Physician Orders for Life-Sustaining Treatment (POLST) hospitalized near the end of life, how often is their inpatient care consistent with POLST-ordered limitations? Findings In this retrospective cohort study of 1818 decedents with POLSTs who were hospitalized within 6 months of death, rates of intensive care unit (ICU) admission differed significantly by POLST order for medical interventions (31% for those who indicated "comfort measures only," 46% for those who indicated "limited additional interventions," and 62% for those who indicated "full treatment"). Meaning For patients hospitalized near the end of life, treatment-limiting POLSTs were associated with significantly lower rates of ICU admission compared with full-treatment POLSTs, although many patients with treatment-limiting POLSTs received care that was potentially discordant with their POLST.