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End-of-life decision making among patients and proxies.

机译：患者和代理之间的生命周期决策。

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摘要

Background. End-of-life (EOL) decision making, including decisions to withdraw mechanical ventilation, can be extremely difficult for patients and their proxies. Advance directives provide proxies with guidance related to EOL decisions. Proxy accuracy ranges from 58% to 79% with the average around 68% (Shalowitz et al., 2006). Patients and proxies have varying levels of trust in the decisions proxies make. Proxy experience with EOL decisions may influence future decisions.;Purpose. To explore patient and proxy decisions related to EOL care and treatment preferences in scenarios representing three distinct disease trajectories. Patient and proxy decisions were explored, and compared for concordance, as they related to the different disease trajectories and directives given by the patient in each of the scenarios.;Methods. This was a secondary data analysis of the "From Contract to Covenant in Advance Care Planning" study (Fins et al., 2005). Participants included 59 patients and 103 inexperienced and experienced proxies. Hypotheses were tested with correlations, crosstabulations, t-tests, repeated measures ANOVAs, and generalized estimating equations.;Results. Patients' mean age was 77.1+7 years, 91.5% were female, and 96.6% were Caucasian. Inexperienced proxies' mean age was 57.6 +16 years, 56.9% were male, and 100% were Caucasian. Experienced proxies' mean age was 60.1+12.5 years, 76.9% were female, and 96.2% were Caucasian. Patient/inexperienced proxy agreement was 48-94% and was highest in the poor prognosis stroke disease trajectory. Modification to directives improved concordance in the uncertain prognosis heart failure trajectory. Proxy agreement ranged from 70.9-95%. GEE analyses revealed proxies with lower education and no history of serious illness were least likely to remove patients from the ventilator. Proxy experience and valence (do everything/do nothing) nested within disease trajectory predicted removal (p = .05); gender and age did not. Patient trust (33.44+6.8) in proxy decisions was higher than proxy trust (30.19+5.5) in their own decisions (p = .05).;Conclusion. This study supported the importance of directives in EOL decision making. In examining agreement and differences in proxy and patient decisions within different disease trajectories, healthcare providers can better understand patient conditions where further interventions are needed. These data suggest that further research related to patients, proxies, and EOL decisions is needed.
机译：背景。对于患者及其代理人而言，寿命终止（EOL）决策（包括撤回机械通气的决策）可能非常困难。预先指示为代理提供与EOL决策相关的指导。代理准确性从58％到79％不等，平均约为68％（Shalowitz等，2006）。患者和代理人对代理人做出的决定有不同程度的信任。具有EOL决策的代理经验可能会影响将来的决策。在代表三种不同疾病轨迹的场景中探索与EOL护理和治疗偏好相关的患者和代理决策。探索了患者和代理人的决策，并比较了它们的一致性，因为它们与每种情况下患者给出的不同疾病轨迹和指示有关。这是对“从合同到预先护理计划中的契约”研究的辅助数据分析（Fins等，2005）。参与者包括59位患者和103位经验不足和经验丰富的代理人。假设用相关性，交叉表，t检验，重复测量方差分析和广义估计方程进行了检验。患者的平均年龄为77.1 + 7岁，女性为91.5％，白种人为96.6％。经验不足的代理人的平均年龄为57.6 +16岁，男性为56.9％，白种人为100％。有经验的代理人的平均年龄为60.1 + 12.5岁，女性为76.9％，白种人为96.2％。患者/经验不足的代理人同意率为48-94％，在预后不良的中风疾病轨迹中最高。修改指令可以改善预后不确定的心力衰竭轨迹的一致性。代理协议的范围为70.9-95％。 GEE分析显示，受教育程度较低且没有大病史的代理人最有可能将患者从呼吸机中撤出。嵌套在疾病轨迹预测去除中的代理经验和效价（什么都做/什么都不做）（p = <.05）；性别和年龄没有。结论：患者对代理决策的信任度（33.44 + 6.8）高于其自己决策的代理信任度（30.19 + 5.5）（p = <.05）。这项研究支持指令在EOL决策中的重要性。通过检查不同疾病轨迹中的代理人和患者决策的一致性和差异，医疗保健提供者可以更好地了解需要进一步干预的患者状况。这些数据表明需要与患者，代理和EOL决策相关的进一步研究。

著录项

  • 作者

    Hinderer, Katherine Ann.;

  • 作者单位

    University of Maryland, Baltimore.;

  • 授予单位 University of Maryland, Baltimore.;
  • 学科 Health Sciences Medical Ethics.;Health Sciences Nursing.
  • 学位 Ph.D.
  • 年度 2010
  • 页码 230 p.
  • 总页数 230
  • 原文格式 PDF
  • 正文语种 eng
  • 中图分类 地球物理学;
  • 关键词

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