2019冠状病毒病大流行一年后，预先护理规划讨论中的差距仍然存在

Originally featured in the American Academy of Home Care Medicine quarterly publication, 前沿.

Why is Advance Care Planning (ACP) of interest to providers of house call medicine? 此时此刻, one year after the attack of COVID, our most frail patients remain at home, fearful of getting sick, isolated from friends and family, and with limited resources to engage in meaningful conversations about their 目标, 值, 和愿望. As privileged providers of in- home care to patients, we have opportunities to connect with our patients, even with face- masks, 盾牌, and other protective equipment. 除了, since March 2020, 我们可以通过使用视频功能的远程医疗平台继续这些对话, like never before, making these interactions more purposeful.

According to a consensus definition by a multidisciplinary Delphi panel, “预先护理计划是一个支持任何年龄或现金足球网哪个好阶段的成年人理解和分享他们个人价值观的过程, 生活目标, and preferences regarding future medical care. 预先护理计划的目标是帮助确保人们得到符合其价值观的医疗护理, 目标, and preferences during serious and chronic illness” (Sudore, 2017). 从这些对话中，可以使用共享的信息完成预先指示文件. Advance directive (AD) documents include living wills, designation of health care proxy, and other documents that serve as legal documentation of patient wishes. 像POLST表格这样的医疗指示是医疗命令，也可以根据这些预先的护理计划对话来完成. These orders are durable and portable and remain in effect across all domains (home, SNF, hospital)(POLST). 完成所有患者的预先指示文件是至关重要的, especially the designation of a healthcare proxy, 谁熟悉病人的愿望，并能帮助使用替代判断，如果病人不再能够表达他们的需求.

这些ACP对话的目的是能够理解对病人最重要的是什么, their hopes and fears, their concerns if their health should decline, 然后了解医疗护理如何最优地与表达的担忧保持一致. 这是一个为患者和家属制定路线图的机会，让他们了解自己现在的处境，以及如果病情恶化，他们可能会去哪里. Through this process, 病人(和代理人)可以积极主动地做出进一步的医疗和其他决定——让他们为自己的护理做主.

研究支持早期ACP对话，因为它们有助于改善患者的生活质量, increased patient emphasis on comfort, increased likelihood of use of hospice services, increased likelihood of a patient dying in their preferred location (home vs. hospital) (Bischoff, 2013), 更不用说, reduced hospital admissions (Chen, 2018), and medical costs (Klinger, 2016)(债券, 2018).

In reviewing the characteristics of who gets ACP conversations, we find that a majority of patients are older age, 高加索人, with a history of chronic disease, higher socioeconomic status, higher education level, and with more significant functional impairments (Teno, 2007) (Orlovic, 2019).

与此形成鲜明对比的是, 研究表明，黑人和西班牙裔不成比例地没有ACP对话(Teno, 2007), lack advance directives (Huang, 2016)(克拉克, 2018), 而且更有可能死在医院，并在生命结束时接受更多的强化治疗(Orlovic), 2019). 研究表明，黑人往往不太可能完成阿尔茨海默病，更倾向于积极的治疗, compared with Whites, which has been thought to be related to distrust of the healthcare system (Kwak, 2005). 这种差异是由种族、文化、社会经济地位还是教育造成的，目前还不清楚. 很明显，这些差距继续存在，需要医疗专业人员和社区团体更加集中的关注.

Other barriers for patients include increased emotion around the topic, 对死亡的恐惧, cultural and legal factors (Committee on Approaching Death, 2015), fear of affecting physician-patient dynamic, fear of affecting family dynamic, 缺少时间, and lack of priority (Bernard, 2020). 为供应商, barriers include fear of patient reaction (emotion, 失去希望), lack of expertise or skill in having these conversations, 时间的承诺, lack of knowledge around ACP vs. 广告大战. orders for life-sustaining treatments, or feeling that someone else is better positioned to have these conversations (Lund,2015)(霍华德, 等, 2018).

What is being done to help to promote further ACP? Senator Blumenthal (D. 康涅狄格州，2020年12月2日《现金足球网哪个好》的发起人，提出了一项法案(S.4945)，该法案增加了对提前护理计划公共教育的资助, training and education to health care workers, telehealth availability to complete ACP, 对国家ACP平台和登记册进行可行性评估，以改善患者和卫生保健提供者的可及性(Famakinwa), 2020) (Congress.政府,2020). 在COVID大流行期间，当患者可能与家人住在一起时，该法案的引入特别有帮助, 在州外, and may not have access to their ACP documents, in which case having improved access is critical.

COVID暴露了患者需要频繁的ACP对话，以表达他们的目标和愿望以及最重要的事情，并选出他们希望代表他们做出决定的人, if they are not able.  由于害怕被戴上呼吸机，许多病人选择不去医院, or even dying in the hospital without the ability to see family. 这一现实突出了确保讨论和记录患者意愿的迫切需要. 所有医护人员都应该接受培训，学习如何进行这些对话，患者应该要求他们的医生围绕ACP进行有意义的讨论. 这个法案, 如果制定, 是否有助于通过远程医疗平台方便地促进更多的这些对话, and with a national registry for improved access.

上门服务和提供者有机会与所有患者联系，了解对他们最重要的事情，并确保尽一切可能使医疗服务与他们的愿望保持一致. 知道特定人群在进行这些有意义的讨论方面得不到充分的服务, 我们的实践可以实施程序和方案，确保所有患者都能得到目标一致的护理.

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). Exploring patient-reported barriers to advance care planning in family practice. BMC Family Practice, 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). Advance Care Planning and the Quality of End‐of‐Life Care in Older Adults. Journal of the American Geriatrics Society, 61(2), 209–214. http://doi.org/10.1111/jgs.12105

布卢门撒尔,R. (2020, December 2). 文本- S.4945 – 116th Congress (2019-2020): Compassionate Care Act (2019/2020) [Webpage]. http://www.国会.gov/bill/116th-国会/senate-

比尔/ 4945 /文本

陈,C. Y., Thorsteinsdottir, 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). 接受家庭姑息治疗的老年人的卫生保健结果和预先护理计划:一项试点队列研究. Journal of Palliative Medicine, 18(1), 38–44. http://doi.org/10.1089/jpm.2014.0150

医患沟通和预先护理计划-美国的死亡- ncbi书架. (n.d.). Retrieved January 18, 2021, from http://www.ncbi.nlm.nih.gov/books/NBK285677/