The last six months of life for patients with congestive heart failure
The last six months of life for patients with congestive heart failure
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DOI：
10.1111/j.1532-5415.2000.tb03119.x
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发表时间：
2000-05-01
影响因子：
6.3
通讯作者：
Phillips, RS
中科院分区：
文献类型：
--
作者：
Levenson, JW;McCarthy, EP;Phillips, RS
目的：描述充血性心力衰竭（CHF）患者在生命最后6个月的经历。设计：前瞻性队列研究数据的回顾性分析。地点：五个地理位置不同的三级医疗学术中心。参与者：共有1404名患者参加了这项研究，以了解预后和对结局和治疗风险的偏好（支持）诊断为CHF急性加重，其中539例患者在1年内死亡，他们的索引industrial.METHODS：从采访患者或其代理人的数据收集和图表摘要进行了几个时间点的支持。为了描述死亡进展，我们构建了四个观察窗口，从患者死亡日期开始，到他们进入支持项目的日期或死亡前6个月结束，以先到者为准。对于每个结局，患者向所有窗口提供信息：他们收集了数据。我们描述了每个结果随时间的频率分布，并报告了trend.OUTCOME MEASURES检验：随时间检查的结果包括：住院天数百分比;基于模型的6个月生存预后估计;功能状态;严重的身体和情绪症状的发生，包括疼痛、抑郁和焦虑;患者对护理的偏好;结果：随着死亡的临近，患者的经济状况越来越差，病情也越来越严重。住院患者的中位急性生理学评分从死亡前6个月至3个月的33分上升到死亡后3天内的44分。然而，即使在死亡后3天内，基于模型的6个月生存率中位数估计值也为54%。随着死亡的临近，功能障碍的数量、中位抑郁评分和报告重度疼痛或呼吸困难的患者百分比增加，41%的患者替代者报告患者在死亡前3天内处于重度疼痛中，63%的患者报告患者严重呼吸短促。感知的生活质量没有明显变化，29%至58%的患者在死亡前的所有时间段报告生活质量良好至极好。随着死亡的临近，患者更倾向于选择不要复苏（DNR）状态，患者选择DNR的比例从死亡前6个月至3个月的33%上升到死亡前1个月至3天的47%（P <0.05）。随着死亡的临近，为住院患者开具DNR命令的频率也在增加。患者的疾病有显着的经济影响，他们的家庭，与23%的患者的家庭报告的大部分或所有的家庭储蓄的损失时，患者的death.CONCLUSIONS：死亡的方法在过去6个月的生活在CHF，疾病变得更加严重，残疾和某些症状的经验更频繁，和患者的偏好不复苏更常见。然而，随着死亡的临近，生活质量并没有显著下降。反映了生命最后一个月期间CHF的不可预测进程，许多患者具有良好的基于模型的6个月中位病程，并享有良好至极好的生活质量。
OBJECTIVE: To characterize the experiences of patients with congestive heart failure (CHF) during their last 6 months of life.DESIGN: A retrospective analysis of data from a prospective cohort study.SETTING: Five geographically diverse tertiary care academic medical centers.PARTICIPANTS: A total of 1404 patients enrolled in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT) with a diagnosis of an acute exacerbation of CHF, of whom 539 patients died within 1 year of their index hospitalization.METHODS: Data from interviews with patients or their surrogates were collected and chart abstractions performed at several time points in SUPPORT. To describe progression to death, we constructed four observational windows backward in time, beginning with patients' dates of death and ending with their date of entry into the SUPPORT project or 6 months before death, whichever came first. For each outcome, patients contributed information to all windows :for which they had data collected. We describe frequency distributions for each outcome over time and report tests for trend.OUTCOME MEASURES: Outcomes examined over time included: percentage of days spent in a hospital; model-based prognostic estimates of 6-month survival; functional status; occurrence of severe physical and emotional symptoms, including pain, depression and anxiety; patients' preferences for care; and the financial impact of patients' illnesses on their families.RESULTS: As death approached, patients' prognoses became poorer and illnesses more severe. Median Acute Physiology Scores for hospitalized patients rose from 33 in the interval 6 months to 3 months before death, to 44 within 3 days of death. However,the median model-based estimate of 6-month survival was 54% even within 3 days of death. Number of functional impairments, median depression scores and percent of patients reporting severe pain or dyspnea increased as death approached, with 41% of patient surrogates reporting that the patient was in severe pain and 63% reporting that the patient was severely short of breath during the 3 days before death. Perceived quality of life did not change appreciably, with 29 to 58 % of patients reporting good to excellent quality of life in all intervals before death. As death approached, patients were more likely to prefer Do Not Resuscitate (DNR) status, with the percent of patients preferring DNR rising from 33% at 6 months to 3 months before death to 47% at 1 month to 3 days before death (P < .05). The frequency with which DNR orders were written for hospitalized patients also increased as death approached. The patients' illnesses had marked financial impact on their families, with 23 % of patients' families reporting the loss of most or all of family savings at the time of the patient's death.CONCLUSIONS: As death approaches during the last 6 months of life in CHF, illness becomes more severe, disability and the experience of certain symptoms more frequent, and patient preference not to be resuscitated more common. However, there is no significant decrement in quality of life as death approaches. Reflecting the unpredictable course of CHF during the last month of life, many patients have good median model-based 6-month prognoses and enjoy good to excellent quality of life.