新冠肺炎大流行一年了, Disparities in Advance Care Planning Discussions Remain

最初刊登在 美国家庭护理医学学会 季度出版, 前沿.

为什么提前护理计划(ACP)对上门医疗服务提供者感兴趣? 在这个时候, 在新冠病毒发作一年后, lg游戏最虚弱的病人都呆在家里, 害怕生病, 与朋友和家人隔绝, 在有限的资源下参与有意义的关于他们目标的对话, 值, 和愿望. 作为病人居家护理的特权提供者, lg游戏有机会和病人交流, 即使带着口罩, 盾牌, 以及其他防护设备. 除了, 2020年3月以来, we can continue these conversations through telemedicine platforms using video capabilities, 前所未有的, 让这些互动更具目的性.

根据多学科专家组的共识定义, “Advance care planning is a process that supports adults at any age or stage of health in understanding and sharing their personal 值, 生活目标, 以及对未来医疗的偏好. The goal of advance care planning is to help ensure that people receive medical care that is consistent with their 值, 目标, 严重和慢性疾病期间的偏好”(苏多尔, 2017). From these conversations, advance directive documents can be completed using the information shared. 预先指示文件包括生前遗嘱, 指定医疗保健代理人, 以及其他作为病人意愿法律文件的文件. Medical directives like the POLST forms are medical orders that also can be completed based on these advance care planning conversations. 这些订单是持久的和可移植的，并且在所有域(主域)上保持有效, SNF, 医院)(POLST). Completion of advance directive documentation on all patients is critically important, 尤其是医疗代理的指定, who is familiar with patient wishes and can help to use substituted judgment if patients are no longer able to articulate their needs.

The purpose of these ACP conversations is to be able to understand what matters most to the patient, 他们的希望和恐惧, 他们担心自己的健康状况是否会下降, and then understand how medical care can most optimally be aligned with expressed concerns. It is an opportunity to set out a roadmap for the patient and family to understand where they are now and where they may be heading if their condition deteriorates. 通过这个过程, the patient (and surrogate) can be proactive in making further medical and other decisions –putting them in the driver’s seat for their own care.

Studies support early ACP conversations as they contribute to improved patient quality of life, 病人越来越重视舒适度, 增加使用临终关怀服务的可能性, 增加患者在其首选地点死亡的可能性(家中vs. 医院)(比肖夫, 2013), 更不用说, 减少住院人数(陈, 2018), 和医疗费用(克林格, 2016)(债券, 2018).

在回顾获得ACP对话者的特征时, lg游戏发现大多数患者年龄较大, 高加索人, 有慢性病史的人, 更高的社会经济地位, 高等教育水平, 并且有更严重的功能障碍(Teno, 2007) (Orlovic, 2019).

与此形成鲜明对比的是, studies show that Blacks and Hispanics disproportionately are not having ACP conversations (Teno, 2007), 缺乏预先指示(黄), 2016)(克拉克, 2018), and are more likely to die in the hospital and receive more intensive treatments at end-of-life (Orlovic, 2019). Studies have shown that Blacks tend to be less likely to complete AD and were more likely to prefer aggressive treatment, 与白人相比, 这被认为与不信任医疗体系有关(郭, 2005). Whether this disparity is due to race, culture, socioeconomic status, or education is not clear. What is clear is that these disparities continue to exist and need more concentrated attention by medical professionals and community groups.

对患者来说，其他障碍包括围绕这个话题的情绪增加, 对死亡的恐惧, 文化和法律因素(逼近死亡委员会), 2015), 害怕影响医患关系, 害怕影响家庭关系, 缺乏时间, 和缺乏优先权(伯纳德, 2020). 为供应商, 障碍包括对病人反应(情绪)的恐惧, 损失的希望), 缺乏进行此类对话的专业知识或技能, 时间的承诺, 缺乏关于ACP的知识vs. 广告大战. 维持生命治疗的订单, 或者感觉其他人更适合进行这些对话(Lund,2015)(霍华德, 等, 2018).

正在采取什么措施来帮助推动非加太的进一步发展? 参议员布卢门撒尔(D. Conn), sponsor of the Compassionate Care Act on December 2, 2020, introduced a bill (S.4945)  to the Senate which increases funding for Advance Care Planning public education, 对卫生保健工作者进行培训和教育, 提供远程保健以完成ACP, feasibility evaluation of a national ACP platform and registry to improve access for patients and health care providers (Famakinwa, 2020)(国会.政府,2020). The introduction of this bill is especially helpful during this COVID pandemic when patients may be living with family members, 州外学生, 可能无法获得他们的ACP文件, 在这种情况下，改善访问是至关重要的.

COVID has brought to light the need for frequent ACP conversations for patients to express their 目标 和愿望 and what matters most and to elect who they would like to make decisions on their behalf, 如果他们不能.  Many patients are choosing to forego the hospital given the fear of being put on a ventilator, 甚至死在医院不能见家人. This reality highlights the critical need to ensure patient wishes are discussed and documented. All healthcare workers should be training in how to have these conversations and patients should be asking their providers to engage in meaningful discussions around ACP. 这个法案, 如果制定, will help facilitate  more of these conversations with  ease of use through telemedicine platforms, 并在全国范围内进行登记，以改善使用情况.

House call practices and providers have an opportunity to connect to all patients on what matters most to them and to ensure that everything possible is being done to facilitate aligning medical care with these wishes. Knowing that specific populations are underserved with regard to having these meaningful discussions, our practices can implement procedures and programs that ensure that all patients can receive goal concordant care.

引用:

伯纳德,C.棕褐色,.、抢米.Elston D.Heyland D. K., & 霍华德,米. (2020). 探索患者报告的家庭实践中提前护理计划的障碍. BMC家庭实践, 21(1), 1–9. http://doi.org/10.1186/s12875-020-01167-0

比绍夫,K. E.Sudore, R.苗族,Y.Boscardin W. J., & 史密斯,. K. (2013). 老年人的提前护理规划与生命末期护理质量. 美国老年病学协会杂志, 61(2), 209–214. http://doi.org/10.1111/jgs.12105

布卢门撒尔,R. (2020年12月2日). 文本,.第4945 - 116届国会(2019-2020):同情护理法案 (2019/2020)(网页). http://www.国会.gov /比尔/ 116 th-国会 /参议院-

比尔/ 4945 /文本

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44.M., & 高桥,P. Y. (2015). Health Care Outcomes and Advance Care Planning in Older Adults Who Receive Home-Based Palliative Care: A Pilot Cohort Study. 缓和医学杂志, 18(1), 38–44. http://doi.org/10.1089/jpm.2014.0150

Clinician-Patient Communication and Advance Care Planning—Dying in America—NCBI Bookshelf. (n.d.). 于2021年1月18日检索 http://www.ncbi.nlm.nih.gov/books/NBK285677/