Association between advance directives and quality of end-of-life care: A national study
Association between advance directives and quality of end-of-life care: A national study
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DOI：
10.1111/j.1532-5415.2007.01045.x
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发表时间：
2007-02-01
影响因子：
6.3
通讯作者：
Wetle, Terrie
中科院分区：
文献类型：
--
作者：
Teno, Joan M.;Gruneir, Andrea;Wetle, Terrie
目的：设计：死亡率追踪调查，研究对象：在疗养院、医院或家中死亡的人，参与者：死者家属或其他知情者。电话采访者询问了书面广告的使用，生命维持治疗的使用，通过询问工作人员是否提供了所需的症状缓解，尊重对待垂死，支持共同决策，协调护理，并为家属提供所需的信息和情感支持，来评估护理质量。结果：在1,587名死亡者中，70.8%患有AD。在临终关怀中心或养老院去世的人更有可能患有AD。此外，AD患者在生命的最后一个月不太可能使用饲管（17% vs 27%）或使用呼吸器（11.8% vs 22.0%）。报告死者没有AD的死者家属更有可能报告与医生沟通（调整后的比值比（AOR）=1.4，95%置信区间（CI）=1.1-1.6）和被告知预期结果（AOR=1.2，95% CI=1.0-1.3）的担忧。在其他结局中未观察到统计学显著差异。即使在AD患者中，重要的质量问题仍然存在;四分之一的患者报告疼痛需求未得到满足，二分之一的患者报告情感支持不足，三分之一的患者报告家庭情感支持不足。丧失亲人的家庭成员报告完成AD与更多地使用临终关怀和更少地报告沟通问题有关，然而，在提高临终关怀质量方面仍然存在着重要的机会。
OBJECTIVES: To examine the role of advance directives (ADs) 10 years after the Patient Self-Determination Act.DESIGN: Mortality follow-back survey.SETTING: People who died in a nursing home, hospital, or at home.PARTICIPANTS: Bereaved family member or other knowledgeable informant.MEASUREMENTS: Telephone interviewers that asked about the use of written ADs, use of life-sustaining treatment, and quality of care by asking whether staff provided desired symptom relief, treated the dying with respect, supported shared decision-making, coordinated care, and provided family with the needed information and emotional support.RESULTS: Of the 1,587 people who died, 70.8% had an AD. Persons who died at home with hospice or in a nursing home were more likely to have an AD. In addition, those with an AD were less likely to have a feeding tube (17% vs 27%) or use a respirator in the last month of life (11.8% vs 22.0%). Bereaved family members who reported that the decedent did not have an AD were more likely to report concerns with physician communication (adjusted odds ratio (AOR)=1.4, 95% confidence interval (CI)=1.1-1.6) and with being informed about what to expect (AOR=1.2, 95% CI=1.0-1.3). No statistically significant differences were observed in other outcomes. Even in those with an AD, important quality concerns remained; one in four reported an unmet need in pain, one in two reported inadequate emotional support for the patient, and one in three stated inadequate family emotional support.CONCLUSION: Bereaved family member report of completion of an AD was associated with greater use of hospice and fewer reported concerns with communication, yet important opportunities remain to improve the quality of end-of-life care.