Advance directive discussions do not lead to death.
Advance directive discussions do not lead to death.
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预先医疗指示讨论不会导致死亡。
DOI：
10.1111/j.1532-5415.2009.02698.x
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发表时间：
2010
影响因子：
6.3
通讯作者：
Kutner,Jean
中科院分区：
文献类型：
--
作者：
Fischer,Stacy;Min,Sung-Joon;Kutner,Jean
重要的参议员在8月13日宣布，生命终结条款将从医疗保健改革法案中删除。引用参议员查尔斯·格拉斯利的话说，该条款将被取消，因为担心它会被误解或不正确地执行。将医疗保险资金用于从业者和患者之间的预先指令（AD）讨论的规定引起了电台脱口秀节目和社交网站上的积极讨论，有时甚至是尖刻的讨论。然而，广告的概念是基于美国的核心伦理原则的自主权。虽然Nancy Cruzan和Terri Schiavo在很短的时间内引起了全国对这个问题的关注，但最近的数据表明，虽然只有约30%的成年人完成了AD（1-3），但93%的成年人愿意与他们的医生讨论AD。(4)现实情况是，这些对话很耗时，与20分钟的预约不相容，而且不计费。医疗保健改革法案将允许医生每五年对AD讨论进行一次补偿，提供指导方针，并建议建立一种机制来跟踪这些讨论的质量。该法案指出（第430页），如果患者的健康状况发生重大变化，AD咨询可能会更频繁地进行。在2003年至2005年期间，我们采访了464名住院患者，询问是否有人与他们讨论过广告。同时进行的病历审查记录了病历中是否存在已完成的AD（请勿复苏命令（其中大多数是在死亡前三天写的（5）），以及其他更广泛类型的AD（生前遗嘱，持久授权书，类似五个愿望的表格））。迄今为止，这些患者中有123人（27%）死亡。使用logistic回归，我们发现在调整年龄和疾病严重程度后，进行过AD讨论或病历中存在AD与1年时死亡或整个随访期内死亡之间没有相关性（表1）。虽然这项研究没有能力检测死亡率或死亡风险的微小差异，但它确实提供了一些数据来告知当前的全国辩论，该辩论有利于尊重患者进行AD讨论的愿望，并确认没有证据表明这些讨论或完成预先指令会导致伤害。
Key senators announced on August 13th that the end of life provision would be dropped from the health care reform bill. Senator Charles Grassley was quoted saying that the provision would be dropped because of fears that it would be misinterpreted or implemented incorrectly. The provision to include Medicare funding for advance directive (AD) discussions between practitioners and patients roused active and, at times vitriolic, discussions on radio talk shows and social networking sites. However, the concept of ADs is based on America’s core ethical principle of autonomy. While Nancy Cruzan and Terri Schiavo brought national attention to the issue for a brief time, recent data suggest while only~ 30% of adults have completed an AD (1–3), 93% of adults would like to discuss ADs with their physician.(4) The reality is that these conversations are time consuming, incompatible with 20 minute appointments, and are not billable. The health care reform bill would have allowed physician compensation for an AD discussion every five years, provided guidelines, and suggested a mechanism to track the quality of these discussions. The bill states (page 430), that an AD consultation could take place more frequently if there were a significant change in the patient’s health status. Those opposed to the end of life provision interpret this to mean that discussing ADs with one’s physician will hasten death.Between 2003 and 2005, we interviewed 464 patients at an index hospitalization and asked if anyone had discussed ADs with them. A concurrent chart review documented the presence or absence of completed ADs in the medical record (Do Not Resuscitate orders (the majority of which are written three days before death (5)), and other broader types of ADs (living will, Durable Power of Attorney, a form like Five Wishes)). To date, 123 (27%) of these patients have died. Using logistic regression, we found no association between having had an AD discussion or the presence of ADs in the medical record and death at one year or death over the complete follow up period after adjusting for age and disease severity (Table 1). While this study was not powered to detect small differences in mortality or risk of death, it does provide some data to inform the current national debate that favors honoring patient wishes to have AD discussions and confirming that there is no evidence that these discussions or completing an advance directive lead to harm.