Concordance Between Proxy Level of Care Preference and Advance Directives Among Nursing Home Residents With Advanced Dementia: A Cluster Randomized Clinical Trial
Concordance Between Proxy Level of Care Preference and Advance Directives Among Nursing Home Residents With Advanced Dementia: A Cluster Randomized Clinical Trial
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DOI：
10.1016/j.jpainsymman.2018.09.018
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发表时间：
2019-01-01
影响因子：
4.7
通讯作者：
Mitchell, Susan L.
中科院分区：
文献类型：
--
作者：
Cohen, Simon M.;Volandes, Angelo E.;Mitchell, Susan L.
上下文与目标一致的护理是预先护理计划（ACP）的预期结果。本研究的目的是检查之间的一致性提前指令和代理护理偏好的养老院居民与晚期痴呆症，并确定ACP视频的影响。数据来自教育视频，以改善终末期痴呆症的护理之家护理，这是一项2013年至2017年在波士顿地区64家机构（32家/组）进行的群集随机临床试验。参与者包括晚期痴呆居民及其代理人（N 1/4 328对）。在基线和每季度（最多12个月），代理人陈述了他们对住院医师的首选护理水平（舒适、基本或强化），并从图表中提取了特定治疗（复苏、住院、管饲、静脉补液、抗生素）的预先指示。在基线时，干预机构的代理人观看了ACP视频。他们在观看后的护理偏好通过与初级护理团队的书面沟通进行分享。在每次评估中，指令和代理偏好之间的一致性被确定。在居民中（平均年龄，86.6岁; 19.5%为男性），最普遍的指令是DNR（89.3%），上述抗生素最不常见（胃肠外，8.2%;任何类型，4.0%）。指令和每个级别的护理偏好之间的一致性如下：舒适，7%;基本，49%;和密集，58%。当舒适护理是首选时，干预机构与对照机构的一致性更高（10.8% vs. 2.5%;校正比值比，2.48; 95%CI，1.01-6.09）。在晚期痴呆症中，需要更好地调整以舒适为中心的护理偏好和预先指示。ACP视频可能有助于实现这一目标。(C)2018年美国临终关怀和姑息医学学会。爱思唯尔公司出版All rights reserved.
Context. Care consistent with goals is the desired outcome of advance care planning (ACP).Objectives. The objectives of this study were to examine concordance between advance directives and proxy care preferences among nursing home residents with advanced dementia and to determine the impact of an ACP video on concordance.Methods. Data were from Educational Video to Improve Nursing home Care in End- stage dementia, a cluster randomized clinical trial conducted in 64 Boston- area facilities (32/arm) from 2013 to 2017. Participants included advanced dementia residents and their proxies (N 1/4 328 dyads). At the baseline and quarterly (up to 12 months), proxies stated their preferred level of care for the resident (comfort, basic, or intensive) and advance directives for specific treatments (resuscitation, hospitalization, tube- feeding, intravenous hydration, antibiotics) were abstracted from the charts. At the baseline, proxies in intervention facilities viewed an ACP video. Their care preferences after viewing it were shared via a written communication with the primary care team. At each assessment, concordance between directives and proxy preferences was determined.Results. Among the residents (mean age, 86.6 years; 19.5% male), the most prevalent directive was DNR (89.3%) and foregoing antibiotics was least common (parenteral, 8.2%; any type, 4.0%). Concordance between directives and each level of care preference was as follows: comfort, 7%; basic, 49%; and intensive, 58%. When comfort care was preferred, concordance was higher in intervention versus control facilities (10.8% vs. 2.5%; adjusted odds ratio, 2.48; 95% CI, 1.01-6.09).Conclusion. Better alignment between preferences for comfort- focused care and advance directives is needed in advanced dementia. An ACP video may help achieve that goal. (C) 2018 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.