Advance directives and outcomes of surrogate decision making before death.
Advance directives and outcomes of surrogate decision making before death.
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DOI：
10.1056/nejmsa0907901
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发表时间：
2010-04-01
期刊：
影响因子：
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通讯作者：
Langa KM
中科院分区：
文献类型：
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作者：
Silveira MJ;Kim SY;Langa KM
最近关于医疗保健改革的讨论提出了关于预先指示价值的问题。我们使用了健康与退休研究中的调查代理数据，这些数据涉及2000年至2006年期间死亡的60岁或60岁以上的成年人，以确定决策需求和决策能力丧失的普遍性，并测试预先指令中记录的偏好与替代决策结果之间的关联。在3746名受试者中，42.5%需要决策，其中70.3%缺乏决策能力，67.6%的受试者有预先指示。与所有可能的护理（1.9%）相比，有生前遗嘱的受试者更可能需要有限护理（92.7%）或舒适护理（96.2%）; 83.2%的受试者要求有限护理，97.1%的受试者要求舒适护理，他们接受的护理与他们的偏好一致。在10例要求所有可能的治疗的受试者中，只有5例接受了治疗;然而，要求所有可能的治疗的受试者与未要求的受试者相比，更有可能接受积极治疗（调整后的比值比，22.62; 95%置信区间[CI]，4.45至115.00）。与没有生前遗嘱的受试者相比，有生前遗嘱的受试者不太可能接受所有可能的护理（调整后的比值比，0.33; 95%CI，0.19至0.56）。与未指定医疗保健永久委托书的受试者相比，指定医疗保健永久委托书的受试者在医院死亡（调整后优势比，0.72; 95%CI，0.55至0.93）或接受所有可能的护理（调整后优势比，0.54; 95%CI，0.34至0.86）的可能性较小。2000年至2006年期间，许多美国老年人在生命即将结束时需要做出决定，而当时大多数人缺乏做出决定的能力。那些准备好了预先指令的患者接受的护理与他们的偏好密切相关。这些调查结果支持继续使用预先指示。
Recent discussions about health care reform have raised questions regarding the value of advance directives. We used data from survey proxies in the Health and Retirement Study involving adults 60 years of age or older who had died between 2000 and 2006 to determine the prevalence of the need for decision making and lost decision-making capacity and to test the association between preferences documented in advance directives and outcomes of surrogate decision making. Of 3746 subjects, 42.5% required decision making, of whom 70.3% lacked decision-making capacity and 67.6% of those subjects, in turn, had advance directives. Subjects who had living wills were more likely to want limited care (92.7%) or comfort care (96.2%) than all care possible (1.9%); 83.2% of subjects who requested limited care and 97.1% of subjects who requested comfort care received care consistent with their preferences. Among the 10 subjects who requested all care possible, only 5 received it; however, subjects who requested all care possible were far more likely to receive aggressive care as compared with those who did not request it (adjusted odds ratio, 22.62; 95% confidence interval [CI], 4.45 to 115.00). Subjects with living wills were less likely to receive all care possible (adjusted odds ratio, 0.33; 95% CI, 0.19 to 0.56) than were subjects without living wills. Subjects who had assigned a durable power of attorney for health care were less likely to die in a hospital (adjusted odds ratio, 0.72; 95% CI, 0.55 to 0.93) or receive all care possible (adjusted odds ratio, 0.54; 95% CI, 0.34 to 0.86) than were subjects who had not assigned a durable power of attorney for health care. Between 2000 and 2006, many elderly Americans needed decision making near the end of life at a time when most lacked the capacity to make decisions. Patients who had prepared advance directives received care that was strongly associated with their preferences. These findings support the continued use of advance directives.