Communication Tools for End-of-Life Decision-Making in Ambulatory Care Settings: A Systematic Review and Meta-Analysis.
Communication Tools for End-of-Life Decision-Making in Ambulatory Care Settings: A Systematic Review and Meta-Analysis.
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DOI：
10.1371/journal.pone.0150671
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发表时间：
2016
期刊：
影响因子：
3.7
通讯作者：
You JJ
中科院分区：
文献类型：
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作者：
Oczkowski SJ;Chung HO;Hanvey L;Mbuagbaw L;You JJ
患有严重疾病的患者及其家属表示，与医疗保健提供者进行更好的沟通和决策是提高临终关怀质量的重中之重。许多沟通工具，以帮助患者，家庭成员和临床医生在临终决策已出版，但其有效性仍不清楚。确定在门诊护理环境中的成年人中，结构化沟通工具对完成提前护理计划的临终决策的影响。我们在MEDLINE、EMBASE、CINAHL、ERIC和科克伦随机对照试验数据库中检索了相关随机对照试验（RCT）或非随机干预研究，数据库创建时间为2014年7月。两名评审员独立筛选文章的合格性，提取数据，并评估偏倚风险。建议评估、制定和评价分级（GRADE）用于评价每个主要和次要结局的证据质量。我们发现了67项研究，其中包括46项随机对照试验，大多数研究评估了没有特定医疗条件的老年患者（年龄>50岁）的沟通工具，但许多研究专门评估了癌症、肺、心脏、神经系统或肾脏疾病患者。大多数研究将沟通工具的使用与常规护理进行了比较，但有几项研究将这些工具与强度较低的提前护理计划工具进行了比较。结构化沟通工具的使用增加：预先护理计划讨论/关于预先指示的讨论的频率（RR 2.31，95% CI 1.25-4.26，p = 0.007，低质量证据）和完成预先指示（AD）（RR 1.92，95% CI 1.43-2.59，p<0.001，低质量证据）; AD偏好与随后使用或不使用生命支持治疗的医嘱之间的一致性（RR 1.19，95% CI 1.01-1.39，p = 0.028，极低质量证据，1项观察性研究）;以及患者期望的护理与接受的护理之间的一致性（RR 1.17，95% CI 1.05-1.30，p = 0.004，低质量证据，2项RCT）。使用结构化的沟通工具可以增加讨论和完成预先指示的频率，以及期望的护理和患者接受的护理之间的一致性。应考虑使用结构化的沟通工具，而不是采用临时性的方法来作出寿命终了决策，应根据当地的需要和情况选择和实施这类工具。PROSPERO CRD 42014012913
Patients with serious illness, and their families, state that better communication and decision-making with healthcare providers is a high priority to improve the quality of end-of-life care. Numerous communication tools to assist patients, family members, and clinicians in end-of-life decision-making have been published, but their effectiveness remains unclear. To determine, amongst adults in ambulatory care settings, the effect of structured communication tools for end-of-life decision-making on completion of advance care planning. We searched for relevant randomized controlled trials (RCTs) or non-randomized intervention studies in MEDLINE, EMBASE, CINAHL, ERIC, and the Cochrane Database of Randomized Controlled Trials from database inception until July 2014. Two reviewers independently screened articles for eligibility, extracted data, and assessed risk of bias. Grading of Recommendations Assessment, Development, and Evaluation (GRADE) was used to evaluate the quality of evidence for each of the primary and secondary outcomes. Sixty-seven studies, including 46 RCTs, were found. The majority evaluated communication tools in older patients (age >50) with no specific medical condition, but many specifically evaluated populations with cancer, lung, heart, neurologic, or renal disease. Most studies compared the use of communication tools against usual care, but several compared the tools to less-intensive advance care planning tools. The use of structured communication tools increased: the frequency of advance care planning discussions/discussions about advance directives (RR 2.31, 95% CI 1.25–4.26, p = 0.007, low quality evidence) and the completion of advance directives (ADs) (RR 1.92, 95% CI 1.43–2.59, p<0.001, low quality evidence); concordance between AD preferences and subsequent medical orders for use or non-use of life supporting treatment (RR 1.19, 95% CI 1.01–1.39, p = 0.028, very low quality evidence, 1 observational study); and concordance between the care desired and care received by patients (RR 1.17, 95% CI 1.05–1.30, p = 0.004, low quality evidence, 2 RCTs). The use of structured communication tools may increase the frequency of discussions about and completion of advance directives, and concordance between the care desired and the care received by patients. The use of structured communication tools rather than an ad-hoc approach to end-of-life decision-making should be considered, and the selection and implementation of such tools should be tailored to address local needs and context. PROSPERO CRD42014012913