One Year Into COVID Pandemic, Disparities in Advance Care Planning Discussions Remain

最初出现在 美国家庭护理医学学会 季度出版, 前沿.

为什么预先护理计划(ACP)对上门医疗服务提供者感兴趣? 此时此刻, 在新冠病毒袭击一年后, 我们最虚弱的病人呆在家里, 害怕生病, 与朋友和家人隔绝, 在有限的资源下，他们无法就自己的目标进行有意义的对话, 值, 和愿望. 作为家庭护理病人的特权提供者, 我们有机会和病人交流, 即使戴着口罩, 盾牌, 以及其他防护设备. 除了, 自2020年3月起, we can continue these conversations through telemedicine platforms using video capabilities, 从未有过的, 让这些互动更有目的.

根据多学科德尔菲专家组的共识定义, “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, 以及对未来医疗护理的偏好. 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(AD)文件包括生前遗嘱, 指定卫生保健代理, 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. 这些命令是持久的和可移植的，并在所有域(家庭)中保持有效, 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, 他们担心自己的现金足球网哪个好状况是否会恶化, 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, 增加病人对舒适度的重视, 使用临终关怀服务的可能性增加, 患者在首选地点(家中与医院)死亡的可能性增加. 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).

在回顾谁得到ACP对话的特征时, 我们发现大多数患者年龄较大, 高加索人, 有慢性病病史, 更高的社会经济地位, 高等教育程度, 以及更严重的功能障碍(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), 缺乏事先指示(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, 这被认为与对医疗系统的不信任有关(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.

患者的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(接近死亡委员会), 2015), 害怕影响医患关系, 害怕影响家庭动态, 缺少时间, 缺乏优先权(伯纳德, 2020). 为供应商, 障碍包括害怕病人的反应(情绪), 失去希望), 缺乏进行这些对话的专业知识或技巧, 时间的承诺, 对ACP缺乏了解. 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(隆德),2015)(霍华德, 等, 2018).

为进一步推动非加太，正在采取哪些措施? 布卢门撒尔参议员(民主党). 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, 远程保健可用于完成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, 在州外, 可能无法访问他们的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, 甚至死在医院里，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, 并有一个国家登记以改善获取.

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.， Tan, A.斯莱文，M.埃尔斯顿，D.马里兰州海兰市. K., & 霍华德,米. (2020). 探索患者报告的障碍，提前护理计划在家庭实践. BMC家庭执业, 21(1), 1–9. http://doi.org/10.1186/s12875-020-01167-0

比绍夫,K. E.苏多尔，R.，苗，Y.W .波斯卡尔丁. J., & 史密斯,. K. (2013). 老年人临终关怀的预先护理计划和质量. 美国老年医学会杂志, 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- S.第116届国会(2019-2020):同情关怀法案 (2019/2020)(网页). http://www.国会.gov /比尔/ 116 th-国会 /参议院-

比尔/ 4945 /文本

陈,C. Y.托尔斯坦斯多蒂尔，B.， Cha, S. S.汉森，G. J.彼得森，S。. M.拉赫曼，P. A.Naessens对这项创新,

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.). 检索于2021年1月18日，来自 http://www.ncbi.nlm.nih.gov/books/NBK285677/