Randomized Controlled Trial of a Structured Intervention to Facilitate End-of-Life Decision Making in Patients With Advanced Cancer
Randomized Controlled Trial of a Structured Intervention to Facilitate End-of-Life Decision Making in Patients With Advanced Cancer
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DOI：
10.1200/jco.2011.40.8872
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发表时间：
2013-09-20
影响因子：
45.3
通讯作者：
Clarke, Stephen J.
中科院分区：
文献类型：
--
作者：
Stein, Rhea A.;Sharpe, Louise;Clarke, Stephen J.
本研究的目的是测试干预对晚期癌症患者临终决策的有效性。患者和方法将120例不再接受治疗意图的转移性癌症患者(以及87名照顾者)随机分为干预组(n=55)和常规治疗组(n=65)。主要的结果衡量指标是不复苏(DNR)患者的比例、DNR命令的时间和死亡地点。在研究登记时、3周后和3个月后完成次要结果测量，包括患者的知识、情绪和照顾者负担。结果两组患者的DNR订单率都很高，但相当。在按方案进行的分析中，接受干预的患者下DNR的时间更早(中位数，27天比12.5天；95%可信区间，1.1到5.9天；P=.03)，他们更有可能避免住院死亡(19%比50%(95%可信区间，11%到50%；P=0.004)。随着时间的推移，两组之间在心肺康复(CPR)成功率的估计方面存在明显差异(P=.01)，但对CPR的了解程度(P=.2)则不明显。没有证据表明干预会导致更多的焦虑或抑郁症状。如果患者接受干预，照顾者在日程安排上的扰乱方面的负担较小(P=0.05)。结论由信息手册和讨论组成的干预与较早下达与死亡相关的DNR订单和降低在医院死亡的可能性相关。尽管样本可能太小，无法发现差异，但干预对次要结果没有负面影响。(C)美国临床肿瘤学会2013年
PurposeThis study tested the efficacy of an intervention on end-of-life decision making for patients with advanced cancer.Patients and MethodsOne hundred twenty patients with metastatic cancer who were no longer being treated with curative intent (and 87 caregivers) were randomly assigned to the intervention (n = 55) or treatment as usual (n = 65). Primary outcome measures were the proportion of patients with do-not-resuscitate (DNR) orders, timing of DNR orders, and place of death. Secondary outcome measures were completed at study enrollment, 3 weeks later, and 3 months later, including patients' knowledge, mood, and caregiver burden.ResultsHigh, but equivalent, rates of DNR orders were observed in both groups. In per-protocol analyses, DNR orders were placed earlier for patients who received the intervention (median, 27 v 12.5 days; 95% CI, 1.1 to 5.9; P =.03) and they were more likely to avoid a hospital death (19% v 50% (95% CI, 11% to 50%; P =.004). Differences between the groups over time were evident for estimates of cardiopulmonary rehabilitation (CPR) success rates (P =.01) but not knowledge of CPR (P =.2). There was no evidence that the intervention resulted in more anxious or depressive symptoms. Caregivers experienced less burden in terms of disruption to schedule if the patient received the intervention (P =.05).ConclusionAn intervention, consisting of an informational pamphlet and discussion, was associated with earlier placement of DNR orders relative to death and less likelihood of death in hospital. There was no negative impact of the intervention on secondary outcomes, although the sample may have been too small to detect differences. (C) 2013 by American Society of Clinical Oncology