The content and clinical utility of psychiatric advance directives
The content and clinical utility of psychiatric advance directives
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DOI：
10.1176/appi.ps.56.5.592
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发表时间：
2005-05-01
影响因子：
3.8
通讯作者：
Holtzheimer, P
中科院分区：
文献类型：
--
作者：
Srebnik, DS;Rutherford, LT;Holtzheimer, P
目的：本文首次对精神病学预先指示的内容和临床实用性进行系统检查，这些文件是在决策妥协时期之前指定治疗偏好的文件。方法：106 名社区精神卫生中心门诊患者在两年内至少接受过两次精神科住院或急诊科就诊，完成了指令。参与者在同伴培训师的带领下以最多六人为一组使用 AD-Maker 软件。临床效用被定义为指导在临床上可行、有用且与护理标准一致的程度。结果：55% 的参与者是女性，24% 是非白人。他们的平均 +/- SD 年龄为 42 +/- 9.1 岁。主要诊断包括精神分裂症谱系障碍（44%）、双相情感障碍（27%）、重度抑郁症（22%）和其他疾病（7%）。 81% 的参与者列出了首选药物，最常见的是抗抑郁药和第二代抗精神病药物，64% 的参与者列出了他们拒绝的药物，最常见的是第一代抗精神病药物。 68% 的人更喜欢住院治疗，89% 的人指定了缓解危机的方法，72% 的人表示他们会拒绝电休克治疗 (ECT)。百分之四十六任命了一位代理决策者。百分之五十七的人希望有一项在丧失行为能力期间不可撤销的指令。至少 95% 的预先指示的指示被评为可行、有用且符合实践标准，但指示中未明确列出的关于是否愿意使用药物的指示除外。结论：结果表明，精神病学预先指示提供了丰富的治疗偏好信息，几乎一致认为这些信息在临床上有用。尽管预先指示的效用可能会根据具体危机事件的情况而有所不同，但所提供的信息可以加快和加强临床护理。
Objective: This paper provides the first systematic examination of the content and clinical utility of psychiatric advance directives, which are documents that specify treatment preferences in advance of periods of compromised decision making. Methods: Directives were completed by 106 community mental health center outpatients with at least two psychiatric hospitalizations or emergency department visits within two years. Participants used AD-Maker software in groups of up to six people led by peer trainers. Clinical utility was defined as the degree to which instructions are clinically feasible, useful, and consistent with standards of care. Results: Fifty-five percent of participants were female, and 24 percent were nonwhite. Their mean +/- SD age was 42 +/- 9.1 years. Primary diagnoses included schizophrenia spectrum disorders ( 44 percent), bipolar disorders ( 27 percent), major depression ( 22 percent), and other disorders ( 7 percent). Eighty-one percent of participants listed preferred medications, most often antidepressants and second-generation antipsychotics, and 64 percent listed medications they would refuse, most commonly first-generation antipsychotics. Sixty-eight percent preferred hospital alternatives over hospitalization, 89 percent specified methods of deescalating crises, and 72 percent indicated that they would refuse electroconvulsive therapy (ECT). Forty-six percent appointed a surrogate decision maker. Fifty-seven percent desired a directive that is irrevocable during periods of incapacity. Instructions were rated as feasible, useful, and consistent with practice standards for at least 95 percent of the advance directives, with the exception of instructions about the willingness to use medications not specifically listed in the directive. Conclusions: Results suggested that psychiatric advance directives provide a wealth of treatment preference information that is almost uniformly considered clinically useful. Although the utility of advance directives may vary depending on the circumstances of specific crisis episodes, the information provided can expedite and strengthen clinical care.