A Randomized Trial of Expanding Choice Sets to Motivate Advance Directive Completion.
A Randomized Trial of Expanding Choice Sets to Motivate Advance Directive Completion.
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DOI：
10.1177/0272989x16663709
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发表时间：
2017-07
期刊：
影响因子：
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通讯作者：
Halpern SD
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作者：
Courtright KR;Madden V;Gabler NB;Cooney E;Kim J;Herbst N;Burgoon L;Whealdon J;Dember LM;Halpern SD
有证据表明，预先指示可能会改善重病患者的临终关怀，但提高完成率仍然是一个挑战。这项研究测试了增加重病患者完成预先医疗指示的选项数量的影响。 2014 年 7 月至 2015 年 7 月期间在费城地区 15 个透析中心接受血液透析的门诊患者 (N=316) 被随机分配接受填写简短预先指示表的选项或包括简短、扩展或综合表格的扩展选项。两组患者都可能拒绝填写预先指示或将他们选择的版本带回家。主要结果是返回一份完整的预先指示。次要结局包括患者是否想要完成预设医疗指示、决策满意度、3 个月时的生活质量以及与完成预设医疗指示相关的患者因素。尽管提供更多预先指示选项与完成率的提高没有显着相关（标准组为 13.1%，扩展组为 12.2%，P=0.80），但它确实显着增加了想要完成预先指示并带一份回家的患者比例（标准组为 71.9%，扩展组为 85.3%，P=0.004）。组间满意度（P=0.65）或生活质量变化（P=0.63）没有差异。较高的基线生活质量与完成预先指示独立相关（P=0.006）。这些结果表明，虽然扩大的选择集最初可能会促使患者在不限制选择的情况下完成预先指示，但增加实际完成情况需要克服下游障碍的额外干预措施。
Evidence suggests that advance directives may improve end-of-life care among seriously ill patients, but improving completion rates remains a challenge. This study tested the influence of increasing the number of options for completing an advance directive among seriously ill patients. Outpatients (N=316) receiving hemodialysis across 15 dialysis centers in the Philadelphia region between July 2014 and July 2015 were randomized to receive either the option to complete a brief advance directive form or expanded options including a brief, expanded, or comprehensive form. Patients in both groups could decline to complete an advance directive or take their selected version home. The primary outcome was a returned, completed advance directive. Secondary outcomes included whether patients wanted to complete an advance directive, decision satisfaction, quality of life at 3 months, and patient factors associated with advance directive completion. Although offering more advance directive options was not significantly associated with increased rates of completion (13.1% in the standard group vs. 12.2% in the expanded group, P=0.80), it did significantly increase the proportion of patients who wanted to complete an advance directive and took one home (71.9% in standard vs. 85.3% in expanded, P=0.004). There was no difference in satisfaction (P=0.65) or change in quality of life between groups (P=0.63). A higher baseline quality of life was independently associated with advance directive completion (P=0.006). These results suggest that although an expanded choice set may initially nudge patients toward completing advance directives without restricting choice, increasing actual completion requires additional interventions that overcome downstream barriers.