Advance directives for seriously ill hospitalized patients: Effectiveness with the Patient Self-Determination Act and the SUPPORT intervention
Advance directives for seriously ill hospitalized patients: Effectiveness with the Patient Self-Determination Act and the SUPPORT intervention
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DOI：
10.1111/j.1532-5415.1997.tb05178.x
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发表时间：
1997-04-01
影响因子：
6.3
通讯作者：
Knaus, WA
中科院分区：
文献类型：
--
作者：
Teno, J;Lynn, J;Knaus, WA
目的：评价书面提前指示(ADS)在危重住院患者护理中的作用。特别是，在ADS由患者自决法(PSDA)促进并通过努力改善研究中的决策以了解预后和对结果的偏好以及治疗(支持)的风险之后进行评估，重点是ADS对关于复苏的决策的影响。设计：观察性队列研究，在PSDA之前(PSDA前)和(PSDA后)2年进行，采用随机、PSDA后改善决策的额外干预的对照试验(职位支持)。设置：美国的五家教学医院PATIENTS：总共有9105名重症患者在五家教学医院接受治疗。干预：PSDA要求患者在入院时对ADS进行教育，并将ADS记录在医疗记录中。此外，支持干预还提供了一名护士，以促进患者、代理人和医生之间就替代治疗方案的偏好和结果进行沟通，并在临床合适的时候鼓励完成和使用ADS。测量：对患者、代理人和主治医生进行了关于ADS的知晓、完成和影响的访谈。回顾病历，讨论有关复苏的偏好、“不要复苏”(DNR)命令的时机和书写、ADS的证据以及死亡时使用或放弃复苏。结果：在三个队列中，前、后和后+支持组的平均年龄为63岁。四分之一的患者在最初住院期间死亡，一半的患者在6个月内死亡，一半的患者在最后3天昏迷。在PSDA(PSDA)之前，62%的人熟悉生前遗嘱，21%的人有AD。这些比率在员额和员额+支持队列中相似。这些指令中只有36个(6%)在Pre的医疗记录中被提及，但有稳定的35%被记录在Post中，并且Post+Support的增长率平均为78%(P
OBJECTIVE: To assess the effectiveness of written advance directives (ADs) in the care of seriously ill, hospitalized patients. In particular, to conduct an assessment after ADs were promoted by the Patient Self-Determination Act (PSDA) and enhanced by the effort to improve decision-making in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT), focusing upon the impact of ADs on decision-making about resuscitation.DESIGN: Observational cohort study conducted for 2 years before (PRE) and for 2 years after (POST) the PSDA, with a randomized, controlled trial of an additional intervention to improve decision-making after the PSDA (POSTS-SUPPORT).SETTING: Five teaching hospitals in the United StatesPATIENTS: A total of 9105 seriously ill patients treated in five teaching hospitals.INTERVENTIONS: The PSDA mandated patient education about ADs at hospital entry and documentation of ADs in the medical record. The SUPPORT intervention, in addition, provided a nurse to facilitate communication among patients, surrogates, and physicians about preferences for and outcomes of treatment alternatives and, when clinically appropriate, to encourage completion and utilization of ADs.MEASUREMENTS: Interviews were conducted with patients, surrogates, and attending physicians about awareness, completion, and impact of ADs. Medical records were reviewed for discussion about preferences concerning resuscitation, timing and writing of ''Do Not Resuscitate'' (DNR) orders, evidence of ADs, and the use or forgoing of resuscitation at the time of death.RESULTS: In the three cohorts, PRE, POST, and POST+SUPPORT, average age was 63. One-quarter of patients died during the initial hospitalization, one-half were dead within 6 months, and one-half were unconscious far their last 3 days. Before the PSDA (PRE), 62% were familiar with a living will, and 21% had an AD. These rates were similar for the POST and POST+SUPPORT cohorts. Just 36 (6%) of these directives were mentioned in the medical records for PRE, but a stable 35% were documented for POST, and POST+SUPPORT had an increasing rate averaging 78% (P