EFFECTS OF OFFERING ADVANCE DIRECTIVES ON MEDICAL TREATMENTS AND COSTS
EFFECTS OF OFFERING ADVANCE DIRECTIVES ON MEDICAL TREATMENTS AND COSTS
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DOI：
10.7326/0003-4819-117-7-599
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发表时间：
1992-10-01
影响因子：
39.2
通讯作者：
LANGER, RD
中科院分区：
文献类型：
--
作者：
SCHNEIDERMAN, LJ;KRONICK, R;LANGER, RD
目的：研究预先指令对医疗、病人满意度和幸福感的影响，并确定通过预先指令增强病人的自主权是否比通过定量配给施加限制提供了一种更道德可行的成本控制方法。204名患者患有危及生命的疾病，其中100人在入组研究后死亡。干预：被随机分配到实验组的患者被提供了加州持久授权书（一个典型的代理指令指令），并分配到对照组的患者没有提供预先指令。对入院情况进行监测，以确保在每次住院时的有效医疗记录中有文件摘要。测量指标：认知功能、患者满意度、心理健康、健康控制点、连贯性、健康相关生活质量、接受医疗和医疗费用。在社会心理变量、健康结果变量和医疗或费用方面，没有发现预先指导组和对照组之间有显著差异。提供预先指示的患者平均住院时间为40.8天（95% CI，32.2至49.4天），而对照组平均住院时间为33.1天（95% CI，26.0至40.2天）。提供预先指示的患者平均收费19502美元（95%置信区间，13 030美元至25 974美元），而在生命的最后一个月，（95%CI，13 704 - 25 696美元）。结论：尽管有人声称公众对长寿的需求是医疗成本上升的原因，但大多数调查显示，患者要求减少而不是增加疾病晚期经常使用的昂贵的高科技治疗。执行加州医疗保健持久授权书并在患者病历中放置摘要副本对患者的福祉、健康状况、医疗或医疗费用没有显著的积极或消极影响。
Objective: To examine the effects of advance directives on medical treatments and on patient satisfaction and well-being and to determine whether the enhancement of patient autonomy through advance directives provides a more ethically feasible approach to cost control than does the imposition of limits through rationing.Design: Randomized, controlled trial.Setting: University and Veterans Affairs medical center.Patients: Two hundred and four patients with life-threatening illnesses, 100 of whom died after enrollment in the study.Intervention: Patients randomly assigned to the experimental group were offered the California Durable Power of Attorney (a typical proxy-instruction directive), and patients assigned to the control group were not offered the advance directive. Hospital admissions were monitored to assure that a summary of the document was present in the active medical record at each hospitalization.Measurements: Cognitive function, patient satisfaction, pyschological well-being, health locus of control, sense of coherence, health-related quality of life, receipt of medical treatments, and medical treatment charges.Results: No significant differences were found between advance-directive and control groups regarding psychosocial variables, health outcome variables, and medical treatments or charges. Patients offered an advance directive had an average hospital stay of 40.8 days (95% Cl, 32.2 to 49.4 days), compared with an average of 33.1 days (95% Cl, 26.0 to 40.2 days) for controls. Patients offered an advance directive were charged an average of $19 502 (95% Cl, $13 030 to $25 974) for medical treatments in the last month of life compared with $19 700 (95% Cl, $13 704 to $25 696) for controls.Conclusions: Despite claims that public demand for longer life accounts for rising medical costs, most surveys suggest that patients are calling for less, not more, of the expensive, high-technology treatment often used in terminal phases of illness. Executing the California Durable Power of Attorney for Health Care and having a summary copy placed in the patient's medical record had no significant positive or negative effect on a patient's well-being, health status, medical treatments, or medical treatment charges.