ADVANCE DIRECTIVES - STABILITY OF PATIENTS TREATMENT CHOICES
ADVANCE DIRECTIVES - STABILITY OF PATIENTS TREATMENT CHOICES
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DOI：
10.1001/archinte.1994.00420020131014
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发表时间：
1994-01-24
影响因子：
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通讯作者：
BARRY, MJ
中科院分区：
文献类型：
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作者：
EMANUEL, LL;EMANUEL, EJ;BARRY, MJ
背景：先行指令的目的是将患者的自主性延长到精神不健全时期。然而，为了实现这一目标，患者的选择必须随着时间的推移保持合理的一致性。因此，我们评估了患者和公众提前治疗决策的稳定性。方法：在对495名门诊患者和102名公众进行的前瞻性队列研究中，我们研究了情景和特定治疗选择的稳定性。作为问卷的一部分，受试者完成了一份提前指示，其中包括四种疾病情景，每种情景有11种治疗选择。296名患者和78名公众在6至12个月后完成了第二次访谈；154名患者在又一次6至12个月后完成了第三次访谈。结果：患者(合并K=0.39)和公众成员(合并K=0.48)的选择稳定性中等偏高。稳定性随着重复访问的增加而提高(在患者中合并K=0.47)。与医生讨论的患者比其他患者有更多的改善(K=0.57)。患者的个人稳定性水平范围很广(0%到100%)，但最初稳定的人很少会变得不那么稳定(在第三次访谈中，85%到100%稳定的患者中有93%保持了这种稳定水平)。住院患者在第二次访谈中的稳定性没有显著差异，但在第三次访谈中他们的稳定性并没有改善。结论：我们的研究结果总体上支持使用提前指令。大多数人在使用特定于情景和治疗的指令时做出了适度稳定的决定，在他们审查了这些决定后，稳定性有所改善，特别是在那些与医生进行了讨论的人中。最近的住院治疗并没有降低稳定性，尽管它似乎减少了其他人通过重复采访所取得的改善。这些发现表明，提前指令可以依赖于完成后1到2年来反映患者的选择。
Background: Advance directives are intended to extend patient autonomy into periods of mental incompetence. However, for advance directives to fulfill this objective, patients' choices must be reasonably consistent over time. Thus, we assessed the stability of the advance treatment decisions of patients and members of the public.Methods: In a prospective cohort study of 495 outpatients and 102 members of the public, we studied the stability of scenarios and treatment-specific choices. Subjects completed an advance directive, which included four illness scenarios with 11 treatment choices in each, as part of a questionnaire. A second interview was completed by 296 patients and 78 members of the public after 6 to 12 months; 154 patients completed a third interview after a further 6 to 12 months. We assessed stability by comparing each choice between interviews.Results: Stability of choices was moderately high among patients (pooled K=0.39) and members of the public (pooled K=0.48). Stability improved with repeat interview (pooled K=0.47 among patients). Patients who had discussions with their physicians showed more improvement (K=0.57) than others. Patients had a wide range of personal stability levels (O% to 100%), but individuals starting out stable rarely became less so (93% of the patients with 85% to 100% stability maintained this level of stability on the third interview). Hospitalized patients showed no significant difference in stability at the second interview, but their stability was not improved at the third interview.Conclusions: Our findings generally support the use of advance directives. Most people made moderately stable decisions when using scenario- and treatment-specific directives, and stability improved after they reviewed the decisions, especially among those who had discussions with their physicians. Recent hospitalization did not decrease stability, although it appeared to reduce the improvement that others achieved with repeat interview. These findings suggest that advance directives can be relied on 1 to 2 years after completion to reflect a patient's choices.