Prior Advance Care Planning Is Associated with Less Decisional Conflict among Surrogates for Critically III Patients
Prior Advance Care Planning Is Associated with Less Decisional Conflict among Surrogates for Critically III Patients
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DOI：
10.1513/annalsats.201504-253oc
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发表时间：
2015-10-01
影响因子：
8.3
通讯作者：
White, Douglas B.
中科院分区：
文献类型：
--
作者：
Chiarchiaro, Jared;Buddadhumaruk, Praewpannarai;White, Douglas B.
理论基础：尽管许多研究记录了重症监护病房的家庭成员为丧失行为能力的患者做出临终决定而苦苦挣扎，但关于事先提前护理计划是否减轻决策负担的信息很少。目的：我们试图衡量危重患者代理人的决策冲突，并检查事先提前护理计划是否与较少的决策冲突相关。方法：我们对在美国五个学术医学中心进行的一项多中心前瞻性队列研究进行了二级数据分析，研究对象包括257名急性呼吸窘迫综合征患者的471名代理人。主要结果是使用决策冲突量表衡量代理人的决策负担。代孕者填写了一份问卷，询问他们之前是否曾与亲人进行过任何提前护理计划的对话。我们使用多水平线性回归模型来衡量决策冲突和提前护理计划之间的关联。测量和主要结果：48%的代孕者存在中度或高度的决策冲突(决策冲突量表得分=25)。在调整了潜在的混杂因素后，参与过事先护理计划对话的代理人的决策冲突水平显著低于没有进行决策冲突的代理人(决策冲突量表的平均得分低3.3分；95%的可信区间为-6.4~-0.2；P=0.03)。结论：近一半的危重病人代理人存在中度或高度的决策冲突。事先的护理计划与较少的决策冲突有关。这些结果表明，提前护理计划的益处范围可能不仅限于尊重患者的意愿，还可以减轻患者亲人作为代理人的负担。
Rationale: Although numerous studies have documented that family members in intensive care units struggle with end-of-life decisions for incapacitated patients, there is little information about whether prior advance care planning lessens the burden of decision making.Objectives: We sought to measure decisional conflict in surrogates of critically ill patients and to examine whether prior advance care planning is associated with less decisional conflict.Methods: We performed a secondary data analysis of a multicenter, prospective cohort study done at five U.S. academic medical centers that included 471 surrogates of 257 patients with acute respiratory distress syndrome. The main outcome was surrogates' burden of decision making as measured using the Decisional Conflict Scale. Surrogates completed a questionnaire item addressing whether they had had any prior advance care planning conversations with their loved ones. We used multilevel linear regression modeling to measure the association between decisional conflict and advance care planning.Measurements and Main Results: Moderate or high levels of decisional conflict (Decisional Conflict Scale score >= 25) were present in 48% of surrogates. After adjusting for potential confounders, surrogates who had engaged in prior advance care planning conversations had significantly lower levels of decisional conflict than those who had not (mean score 3.3 points lower on the Decisional Conflict Scale; 95% confidence interval, -6.4 to -0.2; P = 0.03).Conclusions: Nearly half of surrogates for critically ill patients have moderate or high levels of decisional conflict. Prior advance care planning was associated with less decisional conflict. These results suggest that the scope of the benefit of advance care planning may extend beyond respecting patients' wishes to also ameliorating the burden on patients' loved ones who act as surrogates.