A Randomized Trial of a Family-Support Intervention in Intensive Care Units
A Randomized Trial of a Family-Support Intervention in Intensive Care Units
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DOI：
10.1056/nejmoa1802637
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发表时间：
2018-06-21
影响因子：
158.5
通讯作者：
Arnold, R. M.
中科院分区：
文献类型：
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作者：
White, D. B.;Angus, D. C.;Arnold, R. M.
背景无行为能力的危重患者的代理决策者经常在与护理目标相关的决策上遇到困难。此类决定会导致代理人心理困扰，并可能导致治疗与患者偏好不符。方法我们进行了一项阶梯楔形、整群随机试验，涉及五个重症监护病房 (ICU) 的高死亡风险患者及其代理人，以比较跨专业 ICU 团队提供的多组成部分家庭支持干预措施与常规护理。主要结果是代理人在 6 个月时的医院焦虑和抑郁量表 (HADS) 平均得分（得分范围从 0 到 42，得分越高表明症状越严重）。预先指定的次要结局是替代者在事件影响量表（IES；分数范围从 0 到 88，分数越高表示症状越差）、沟通质量 (QOC) 量表（分数范围从 0 到 100，分数越高表示临床医生与家庭沟通越好）以及改良的患者对患者中心性的感知 (PPPC) 量表（分数范围从 1 到 4，分数越低表示患者和家属的沟通越多）的平均分数。以家庭为中心的护理），以及 ICU 住院的平均时间。 结果共有 1420 名患者参加了试验。干预组和对照组在 6 个月时代理人的平均 HADS 评分（分别为 11.7 和 12.0；β 系数，-0.34；95% 置信区间 [CI]，-1.67 至 0.99；P = 0.61）或平均 IES 评分（21.2 和 20.3；β 系数，0.90；95% CI， -1.66 至 3.47；P = 0.49）。干预组中替代者的平均 QOC 评分优于对照组（69.1 vs. 62.7；β 系数，6.39；95% CI，2.57 至 10.20；P = 0.001），平均修正 PPPC 评分也好（1.7 vs. 1.8；β 系数，-0.15；95% CI，-0.26 至-0.04；P = 0.006)。干预组在 ICU 的平均住院时间比对照组短（6.7 天 vs. 7.4 天；发病率比，0.90；95% CI，0.81 至 1.00；P = 0.045），这一发现是由死亡患者在 ICU 的平均住院时间缩短所介导的（4.4 天 vs. 6.8 天；发病率比，0.64；P = 0.045）。 95% CI，0.52 至 0.78；
BACKGROUNDSurrogate decision makers for incapacitated, critically ill patients often struggle with decisions related to goals of care. Such decisions cause psychological distress in surrogates and may lead to treatment that does not align with patients' preferences.METHODSWe conducted a stepped-wedge, cluster-randomized trial involving patients with a high risk of death and their surrogates in five intensive care units (ICUs) to compare a multicomponent family-support intervention delivered by the interprofessional ICU team with usual care. The primary outcome was the surrogates' mean score on the Hospital Anxiety and Depression Scale (HADS) at 6 months (scores range from 0 to 42, with higher scores indicating worse symptoms). Prespecified secondary outcomes were the surrogates' mean scores on the Impact of Event Scale (IES; scores range from 0 to 88, with higher scores indicating worse symptoms), the Quality of Communication (QOC) scale (scores range from 0 to 100, with higher scores indicating better clinician-family communication), and a modified Patient Perception of Patient Centeredness (PPPC) scale (scores range from 1 to 4, with lower scores indicating more patient-and family-centered care), as well as the mean length of ICU stay.RESULTSA total of 1420 patients were enrolled in the trial. There was no significant difference between the intervention group and the control group in the surrogates' mean HADS score at 6 months (11.7 and 12.0, respectively; beta coefficient, -0.34; 95% confidence interval [CI], -1.67 to 0.99; P = 0.61) or mean IES score (21.2 and 20.3; beta coefficient, 0.90; 95% CI, -1.66 to 3.47; P = 0.49). The surrogates' mean QOC score was better in the intervention group than in the control group (69.1 vs. 62.7; beta coefficient, 6.39; 95% CI, 2.57 to 10.20; P = 0.001), as was the mean modified PPPC score (1.7 vs. 1.8; beta coefficient, -0.15; 95% CI, -0.26 to -0.04; P = 0.006). The mean length of stay in the ICU was shorter in the intervention group than in the control group (6.7 days vs. 7.4 days; incidence rate ratio, 0.90; 95% CI, 0.81 to 1.00; P = 0.045), a finding mediated by the shortened mean length of stay in the ICU among patients who died (4.4 days vs. 6.8 days; incidence rate ratio, 0.64; 95% CI, 0.52 to 0.78; P