Trends in advance care planning and end-of-life care among persons living with dementia requiring surrogate decision-making.
Trends in advance care planning and end-of-life care among persons living with dementia requiring surrogate decision-making.
复制标题
痴呆症患者的提前护理计划和临终关怀的趋势需要替代决策。
DOI：
10.1111/jgs.17680
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发表时间：
2022-05
影响因子：
6.3
通讯作者：
Tsugawa, Yusuke
中科院分区：
文献类型：
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作者：
Gotanda, Hiroshi;Walling, Anne M.;Reuben, David B.;Lauzon, Marie;Tsugawa, Yusuke
先前的研究已经证明了预先护理计划（ACP）对生命终结（EOL）护理的积极影响。我们试图检查痴呆患者（PLWD）在生命最后几天需要替代决策的ACP和EOL护理强度的趋势。我们分析了健康与退休研究（HRS）的参与者，这是一项具有全国代表性的美国居民纵向面板研究，患有70岁及以上的痴呆症，在生命的最后几天需要替代决策，并在2000年至2014年期间死亡。基于参与者死亡后的替代报告，我们的研究测量了三种特定类型的患者参与ACP的完成情况（书面EOL护理指示、医疗保健持久委托书的分配、患者参与EOL护理讨论）和生命最后几天的四种EOL护理措施（住院死亡、接受延长生命的治疗、限制或不接受某些治疗、接受舒适护理）。所有的分析都解释了HRS复杂的调查设计。在2000-2014年间死亡的870名成年痴呆患者（加权N= 2,812,380）中，只有34.8%的患者参与了ACP的所有三个方面，并且在2000-2014年间，ACP的完成率没有显著增加。在生命的最后几天接受延长生命治疗的人数随着时间的推移而增加（每年调整变化，1.4个百分点[pp]； 95% CI， 0.5至2.2pp；趋势p =0.002），而住院死亡、限制或拒绝某些治疗或舒适护理的百分比没有变化。我们的研究结果表明，尽管ACP有潜在的益处，但ACP完成率并没有随着时间的推移而增加，而且在需要替代决策的PLWD中，延长生命的治疗仍然很常见，这一人群可能从早期ACP中获益很大。
Previous studies have demonstrated positive impacts of advance care planning (ACP) on end-of-life (EOL) care. We sought to examine trends in ACP and EOL care intensity among persons living with dementia (PLWD) who required surrogate decision-making in their final days of life. We analyzed the participants of the Health and Retirement Study (HRS), a nationally representative longitudinal panel study of U.S. residents, with dementia 70 years and older who required surrogate decision-making in the final days of life and died between 2000 and 2014. Based on surrogate reports after the death of a participant, our study measured the completion of three specific types of patient-engaged ACP (written EOL care instructions, assignment of a durable power of attorney for healthcare, patient engagement in EOL care discussions) and four measures of EOL care in the final days of life (death in hospital, receipt of life-prolonging treatments, limiting or withholding certain treatments, and receipt of comfort-oriented care). All analyses accounted for the complex survey design of HRS. Among 870 adults (weighted N= 2,812,380) with dementia who died in 2000-2014 and required surrogate decision making at EOL, only 34.8% of patients participated in all three aspects of ACP, and there was not a significant increase in ACP completion between 2000 and 2014. The receipt of life-prolonging treatments in the final days of life has increased over time (adjusted change per year, 1.4 percentage points [pp]; 95% CI, 0.5pp to 2.2pp; P-for-trend=0.002), while the percentage of death in hospital, limiting or withholding certain treatments, or comfort-oriented care did not change. Our findings suggest that the rates of ACP completion have not increased over time despite its potential benefits and life-prolonging treatments are still common among PLWD who require surrogate decision-making, a population who might benefit greatly from early ACP.
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