Effect of Palliative Care-Led Meetings for Families of Patients With Chronic Critical Illness A Randomized Clinical Trial
Effect of Palliative Care-Led Meetings for Families of Patients With Chronic Critical Illness A Randomized Clinical Trial
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DOI：
10.1001/jama.2016.8474
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发表时间：
2016-07-05
影响因子：
120.7
通讯作者：
Nelson, Judith E.
中科院分区：
文献类型：
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作者：
Carson, Shannon S.;Cox, Christopher E.;Nelson, Judith E.
重要性慢性危重病患者的家庭照顾者经历显着的心理distress.Objective确定是否由姑息治疗临床医生领导的家庭信息和情感支持会议改善家庭anxiety and depression. DESIGN，SETTING，AND PARTICIPANTS一项多中心随机临床试验，从2010年10月至2014年11月在4个医疗重症监护病房（ICU）进行。将需要7天机械通气的成人患者（年龄≥ 21岁）随机化，并将其家庭代理决策者纳入研究。观察员不知情组分配的测量的主要outcomes.INTERVENTIONS至少有2个结构化的家庭会议领导的姑息治疗专家和提供的信息手册（干预）相比，提供的信息手册和常规的家庭会议进行ICU团队（对照）。干预组130例，家庭代理决策者184人，对照组126例，家庭代理决策者181人。主要结果与指标（HADS;评分范围，0 [最佳]至42 [最差];最小临床重要差异，1.5）在与替代决策者的3个月随访访谈期间获得。次要结果包括创伤后应激障碍经历的家庭和测量的影响事件量表修订版（IES-R;总评分范围，0 [最好]至88 [最差]），讨论患者的喜好，住院时间，和90天survival.RESULTS在365家庭代理决策者（平均年龄，51岁，71%女性），312完成了研究。在3个月时，干预组和对照组的代理决策者之间的焦虑和抑郁症状没有显著差异（调整后的平均HADS评分分别为12.2和11.4;组间差异为0.8 [95%CI，-0.9至2.6]; P = 0.34）。干预组的创伤后应激障碍症状（IES-R评分调整后平均值为25.9）高于对照组（IES-R评分调整后平均值为21.3）（组间差异为4.60 [95%CI，0.01 - 9.10]; P = 0.0495）。两组之间关于患者偏好的讨论没有差异（干预，75%;对照，83%;比值比，0.63 [95%CI，0.34至1.16; P = 0.14]）。干预组与对照组患者的中位住院天数（分别为19天vs 23天;组间差异，-4天[95% CI，-6至3天]; P = 0.51）和90天生存期（风险比，0.95 [95% CI，0.65 - 1.38]，P = 0.96）无显著差异。结论和相关性在慢性危重病患者的家庭中，与常规护理相比，使用姑息护理主导的信息和情感支持会议并没有减少焦虑或抑郁症状，反而可能增加创伤后应激障碍症状。这些研究结果不支持常规或强制性姑息治疗主导的讨论目标的护理慢性危重病患者的所有家庭。
IMPORTANCE Family caregivers of patients with chronic critical illness experience significant psychological distress.OBJECTIVE To determine whether family informational and emotional support meetings led by palliative care clinicians improve family anxiety and depression.DESIGN, SETTING, AND PARTICIPANTS A multicenter randomized clinical trial conducted from October 2010 through November 2014 in 4 medical intensive care units (ICUs). Adult patients (aged >= 21 years) requiring 7 days of mechanical ventilation were randomized and their family surrogate decision makers were enrolled in the study. Observers were blinded to group allocation for the measurement of the primary outcomes.INTERVENTIONS At least 2 structured family meetings led by palliative care specialists and provision of an informational brochure (intervention) compared with provision of an informational brochure and routine family meetings conducted by ICU teams (control). There were 130 patients with 184 family surrogate decision makers in the intervention group and 126 patients with 181 family surrogate decision makers in the control group.MAIN OUTCOMES AND MEASURES The primary outcome was Hospital Anxiety and Depression Scale symptom score (HADS; score range, 0[best] to 42[worst]; minimal clinically important difference, 1.5) obtained during 3-month follow-up interviews with the surrogate decision makers. Secondary outcomes included posttraumatic stress disorder experienced by the family and measured by the Impact of Events Scale-Revised (IES-R; total score range, 0 [best] to 88 [worst]), discussion of patient preferences, hospital length of stay, and 90-day survival.RESULTS Among 365 family surrogate decision makers (mean age, 51 years; 71% female), 312 completed the study. At 3 months, there was no significant difference in anxiety and depression symptoms between surrogate decision makers in the intervention group and the control group (adjusted mean HADS score, 12.2 vs 11.4, respectively; between-group difference, 0.8 [95% CI, -0.9 to 2.6]; P = .34). Posttraumatic stress disorder symptoms were higher in the intervention group (adjusted mean IES-R score, 25.9) compared with the control group (adjusted mean IES-R score, 21.3) (between-group difference, 4.60 [95% CI, 0.01 to 9.10]; P = .0495). There was no difference between groups regarding the discussion of patient preferences (intervention, 75%; control, 83%; odds ratio, 0.63[95% CI, 0.34 to 1.16; P = .14]). The median number of hospital days for patients in the intervention vs the control group (19 days vs 23 days, respectively; between-group difference, -4 days [95% CI, -6 to 3 days]; P = .51) and 90-day survival (hazard ratio, 0.95 [95% CI, 0.65 to 1.38], P = .96) were not significantly different.CONCLUSIONS AND RELEVANCE Among families of patients with chronic critical illness, the use of palliative care-led informational and emotional support meetings compared with usual care did not reduce anxiety or depression symptoms and may have increased posttraumatic stress disorder symptoms. These findings do not support routine or mandatory palliative care-led discussion of goals of care for all families of patients with chronic critical illness.