Strategic Targeting of Advance Care Planning Interventions The Goldilocks Phenomenon
Strategic Targeting of Advance Care Planning Interventions The Goldilocks Phenomenon
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DOI：
10.1001/jamainternmed.2013.14384
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发表时间：
2014-04-01
影响因子：
39
通讯作者：
Bernacki, Rachelle
中科院分区：
文献类型：
--
作者：
Billings, J. Andrew;Bernacki, Rachelle
策略性地选择患者进行关于限制生命维持治疗的讨论和记录，选择合适的时间沿着生命终结轨迹进行这种干预，并识别面临生命终结决策的高风险患者，可以对预先护理计划（ACP）工作的价值产生深远的影响。时机很重要，因为提前指令（AD）的完成距离死亡时间太远或太近，可能导致无法最佳反映患者价值观，目标和偏好的临终决策：在不久的将来不太可能需要AD的不良选择的目标患者群体可能导致患者做出不切实际的、假设的选择，而在灾难面前评估急诊室或医院的偏好是众所周知的不足。由于目前研究的大部分ACP工作导致最终从AD中获益的患者比例低得令人不安，因此仔细确定干预目标也应该提高此类项目的有效性。ACP计划目标患者的最佳时机和战略选择的关键是精确化，我们简要强调了精确化工具和研究，这些工具和研究可能为我们提供高价值的AD干预措施。
Strategically selecting patients for discussions and documentation about limiting life-sustaining treatments-choosing the right time along the end-of-life trajectory for such an intervention and identifying patients at high risk of facing end-of-life decisions-can have a profound impact on the value of advance care planning (ACP) efforts. Timing is important because the completion of an advance directive (AD) too far from or too close to the time of death can lead to end-of-life decisions that do not optimally reflect the patient's values, goals, and preferences: a poorly chosen target patient population that is unlikely to need an AD in the near future may lead to patients making unrealistic, hypothetical choices, while assessing preferences in the emergency department or hospital in the face of a calamity is notoriously inadequate. Because much of the currently studied ACP efforts have led to a disappointingly small proportion of patients eventually benefitting from an AD, careful targeting of the intervention should also improve the efficacy of such projects. A key to optimal timing and strategic selection of target patients for an ACP program is prognostication, and we briefly highlight prognostication tools and studies that may point us toward high-value AD interventions.