Improving Communication in Heart Failure Patient Care
Improving Communication in Heart Failure Patient Care
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DOI：
10.1016/j.jacc.2019.07.058
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发表时间：
2019-10-01
影响因子：
24
通讯作者：
Morrison, R. Sean
中科院分区：
文献类型：
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作者：
Goldstein, Nathan E.;Mather, Harriet;Morrison, R. Sean
背景 尽管植入式心律转复除颤器（ICD）可降低猝死风险，但这些患者仍会死于心力衰竭（HF）或其他疾病。为避免临终时的电击，临床医生应讨论停用除颤功能。
目的 本研究旨在确定以临床医生为中心的教学干预和自动提醒是否会增加ICD停用的讨论以及设备停用的情况。
方法 在这项6中心、单盲、整群随机对照试验中，主要结局指标是患者的比例：1）进行ICD停用讨论；2）除颤功能被停用。次要结局包括治疗目标的沟通以及预先指示的完成情况。
结果 共纳入525名患有晚期心力衰竭且植入ICD的受试者：301名干预组，224名对照组。基线时，52%（n = 272）的患者不适合接受高级治疗（即心脏移植或机械循环支持）。在讨论（41[14%]对26[12%]）或停用（33[11%]对26[12%]）方面没有差异。在对不适合接受高级治疗的患者进行的预先设定的亚组分析中，干预措施增加了停用讨论（32[25%]对16[11%]；比值比：2.90；p = 0.003）。总体而言，99名患者死亡；死者之间在沟通或停用方面没有差异。次要结局：在所有参与者中，治疗目标沟通有所增加（干预组47%对对照组38%；比值比：1.53；p = 0.04）。预先指示的完成情况没有差异。
结论 该干预措施增加了关于ICD停用和治疗目标的沟通。心力衰竭临床医生能够根据患者的病情严重程度应用新的沟通技巧。（改善植入式心律转复除颤器停用沟通的干预措施[WISDOM]；NCT01459744）由爱思唯尔代表美国心脏病学会基金会发表。
BACKGROUND Although implantable cardioverter-defibrillators (ICDs) reduce sudden death, these patients die of heart failure (HF) or other diseases. To prevent shocks at the end of life, clinicians should discuss deactivating the defibrillation function.OBJECTIVES The purpose of this study was to determine if a clinician-centered teaching intervention and automatic reminders increased ICD deactivation discussions and increased device deactivation.METHODS In this 6-center, single-blinded, cluster-randomized, controlled trial, primary outcomes were proportion of patients: 1) having ICD deactivation discussions; and 2) having the shocking function deactivated. Secondary outcomes included goals of care conversations and advance directive completion.RESULTS A total of 525 subjects were included with advanced HF who had an ICD: 301 intervention and 224 control. At baseline, 52% (n = 272) were not candidates for advanced therapies (i.e., cardiac transplant or mechanical circulatory support). There were no differences in discussions (41 [14%] vs. 26 [12%]) or deactivation (33 [11%] vs. 26 [12%]). In pre-specified subgroup analyses of patients who were not candidates for advanced therapies, the intervention increased deactivation discussions (32 [25%] vs. 16 [11%]; odds ratio: 2.90; p = 0.003). Overall, 99 patients died; there were no differences in conversations or deactivations among decedents. Secondary outcomes: Among all participants, there was an increase in goals of care conversations (47% intervention vs. 38% control; odds ratio: 1.53; p = 0.04). There were no differences in completion of advance directives.CONCLUSIONS The intervention increased conversations about ICD deactivation and goals of care. HF clinicians were able to apply new communication techniques based on patients' severity of illness. (An Intervention to Improve Implantable Cardioverter-Defibrillator Deactivation Conversations [WISDOM]; NCT01459744) Published by Elsevier on behalf of the American College of Cardiology Foundation.