A PROSPECTIVE-STUDY OF ADVANCE DIRECTIVES FOR LIFE-SUSTAINING CARE
A PROSPECTIVE-STUDY OF ADVANCE DIRECTIVES FOR LIFE-SUSTAINING CARE
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DOI：
10.1056/nejm199103283241304
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发表时间：
1991-03-28
影响因子：
158.5
通讯作者：
PATRICK, DL
中科院分区：
文献类型：
--
作者：
DANIS, M;SOUTHERLAND, LI;PATRICK, DL
背景资料。建议使用预先指令，以便人们可以确定当他们不再有能力时将接受的医疗护理，但此类指令的有效性尚不清楚。在一项为期两年的前瞻性研究中，对一家疗养院的126名有能力的居民和49名无能力的患者的家庭成员进行了采访，以确定他们在危重疾病、晚期疾病或永久性昏迷时的住院、重症监护、心肺复苏、人工呼吸机、手术和导管喂养方面的偏好。预先指示，包括签署的治疗偏好声明，被放置在医疗记录中，以帮助疗养院的护理，并在必要时转发到医院。在对96起结局事件(在疗养院住院或死亡)的分析中，75%的护理与先前表达的愿望一致；然而，医疗记录中存在书面预先指示并不利于一致性。在发生不一致的24个事件中，有6个病例提供的护理比要求的更积极，这主要是因为意外的手术或人工呼吸，而18个病例的护理没有要求的那么积极，主要是因为住院或心肺复苏被推迟。疗养院比医院更容易出现不一致的情况。书面预先指示的有效性受到忽视，以及决定优先考虑患者自主权以外的其他因素的限制。由于我们的研究只在一家疗养院和一家医院进行，因此需要其他研究来确定我们发现的普遍性。
Background. The use of advance directives is recommended so that people can determine the medical care they will receive when they are no longer competent, but the effectiveness of such directives is not clear.Methods. In a prospective study conducted over a two-year period, 126 competent residents of a nursing home and 49 family members of incompetent patients were interviewed to determine their preferences with respect to hospitalization, intensive care, cardiopulmonary resuscitation, artificial ventilation, surgery, and tube feeding in the event of critical illness, terminal illness, or permanent unconsciousness. Advance directives, consisting of signed statements of treatment preferences, were placed in the medical record to assist in care in the nursing home and to be forwarded to the hospital if necessary.Results. In an analysis of 96 outcome events (hospitalization or death in the nursing home), care was consistent with previously expressed wishes 75 percent of the time; however, the presence of the written advance directive in the medical record did not facilitate consistency. Among the 24 events in which inconsistencies occurred, care was provided more aggressively than had been requested in 6 cases, largely because of unanticipated surgery or artificial ventilation, and less aggressively than requested in 18, largely because hospitalization or cardiopulmonary resuscitation was withheld. Inconsistencies were more likely in the nursing home than in the hospital.Conclusions. The effectiveness of written advance directives is limited by inattention to them and by decisions to place priority on considerations other than the patient's autonomy. Since our study was performed in only one nursing home and one hospital, other studies are necessary to determine the generalizability of our findings.