Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment.
Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment.
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DOI：
10.1001/jama.300.14.1665
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发表时间：
2008-10-08
影响因子：
120.7
通讯作者：
Prigerson, Holly G.
中科院分区：
文献类型：
--
作者：
Wright, Alexi A.;Zhang, Baohui;Ray, Alaka;Mack, Jennifer W.;Trice, Elizabeth;Balboni, Tracy;Mitchell, Susan L.;Jackson, Vicki A.;Block, Susan D.;Maciejewski, Paul K.;Prigerson, Holly G.
谈论死亡可能很困难。如果没有证据表明临终（EOL）讨论可以改善患者的预后，医生必须在荣誉患者自主权的愿望与临终讨论可能造成心理伤害的担忧之间进行平衡。确定与医生进行的EOL讨论是否与更少的积极干预相关。一项美国多中心、前瞻性、纵向队列研究，研究对象为晚期癌症患者及其非正式护理者（n=332对），2002年9月至2008年2月。患者从入组到死亡的平均随访时间为4.4个月。在中位6.5个月后评估丧失照顾者的精神疾病和生活质量（QoL）。主要结局是积极的医疗护理（例如，在生命的最后一周进行通气、复苏）和临终关怀。次要结果包括患者的心理健康和照顾者的丧亲适应。332例患者中有123例（37.0%）在基线前报告了EOL讨论。EOL讨论与更高的重度抑郁症发生率（8.3% vs. 5.8; AOR 1.33，95% CI 0.54-3.32）或更多的“担忧”（6.5 vs. 7.0; p=0.19）无关。倾向评分加权调整后，终末期讨论与较低的通气率相关（1.6% vs. 11.0%; AOR 0.26，95% CI 0.08-0.83），复苏（0.8% vs. 6.7%; AOR 0.16，95% CI 0.03-0.80），入住ICU（4.1 vs. 12.4%; AOR 0.35，95% CI 0.14-0.90）和早期临终关怀招募（65.6% vs. 44.5%; AOR 1.58，95% CI 1.04-2.63）。在校正分析中，更积极的医疗护理与更差的患者生活质量相关（6.4 vs. 4.6; F=3.60，p=0.01），丧失亲人的照顾者患重度抑郁症的风险更高（AOR 3.37，95% CI 1.12-10.13），而更长的临终关怀住院时间与更好的患者QoL相关（5.6 vs. 6.9; F=3.70，p=0.01）。患者生活质量越好，随访时护理人员生活质量越好（β=0.20; p=0.001）。EOL讨论与接近死亡的较不积极的医疗护理和较早的临终关怀转诊有关。积极的护理与更差的患者生活质量和更差的丧亲适应相关。
Talking about death can be difficult. Without evidence that end-of-life (EOL) discussions improve patient outcomes, physicians must balance their desire to honor patient autonomy against a concern that EOL discussions may inflict psychological harm. To determine whether EOL discussions with physicians are associated with fewer aggressive interventions. A United States multi-site, prospective, longitudinal cohort study of advanced cancer patients and their informal caregivers (n=332 dyads), September 2002-February 2008. Patients were followed from enrollment to death a median of 4.4 months later. Bereaved caregivers’ psychiatric illness and quality of life (QoL) was assessed a median 6.5 months later. The primary outcome were aggressive medical care (e.g., ventilation, resuscitation) and hospice in the final week of life. Secondary outcomes included patients’ mental health and caregivers’ bereavement adjustment. 123 of 332 (37.0%) patients reported EOL discussions before baseline. EOL discussions were not associated with higher rates of Major Depressive Disorder (8.3% vs. 5.8; AOR 1.33, 95% CI 0.54-3.32), or more “worry” (6.5 vs. 7.0; p=0.19)). After propensity-score weighted adjustment, EOL discussions were associated with lower rates of ventilation (1.6% vs. 11.0%; AOR 0.26, 95% CI 0.08-0.83), resuscitation (0.8% vs. 6.7%; AOR 0.16, 95% CI 0.03-0.80), ICU admission (4.1 vs. 12.4%; AOR 0.35, 95% CI 0.14-0.90), and earlier hospice enrollment (65.6% vs. 44.5%; AOR 1.58, 95% CI 1.04-2.63). In adjusted analyses, more aggressive medical care was associated with worse patient QoL (6.4 vs. 4.6; F=3.60, p=0.01) and higher risk for Major Depressive Disorder in bereaved caregivers (AOR 3.37, 95% CI 1.12-10.13), while longer hospice stays were associated with better patient QoL (5.6 vs. 6.9; F=3.70, p=0.01). Better patient QoL was associated with better caregiver QoL at follow-up (β=0.20; p=0.001). EOL discussions are associated with less aggressive medical care near death and earlier hospice referrals. Aggressive care is associated with worse patient QoL and worse bereavement adjustment.
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影响因子：
10.3
作者：
Albano, Jessica D.;Ward, Elizabeth;Thun, Michael J.
通讯作者：
Thun, Michael J.
影响因子：
2.2
作者：
Gordon, EJ;Daugherty, CK
通讯作者：
Daugherty, CK
DOI：
10.1046/j.1532-5415.2003.51457.x
发表时间：
2003-10-01
影响因子：
6.3
作者：
Fried, TR;Bradley, EH;O'Leary, J
通讯作者：
O'Leary, J
DOI：
10.1097/01.jgp.0000194642.86116.ce
发表时间：
2006-03-01
影响因子：
7.2
作者：
Kris, AE;Cherlin, EJ;Bradley, EH
通讯作者：
Bradley, EH
影响因子：
45.3
作者：
Baile, WF;Lenzi, R;Cohen, L
通讯作者：
Cohen, L