美国华盛顿大学Robert Y. Lee课题组进行了临终病人预立维生医嘱与ICU入院的相关性研究。相关论文发表在2020年2月16日出版的《美国医学会杂志》上。

慢性病患者经常使用预立维生医嘱（POLST）来记录治疗限制。

为了探讨临终关怀病房（ICU）收治与POLST医疗干预政策的相关性，研究组对2010年1月1日至2017年12月31日期间死亡，且在死亡前6个月内住院的有POLST的慢性病患者进行了一项回顾性队列研究。

1818名死者的平均年龄为70.8岁，41%为女性，401名（22%）只接受过舒适治疗的POLST干预，761名（42%）接受过选择性治疗干预，656名（36%）接受过完整治疗。

31%只接受舒适治疗的患者、46%接受选择性治疗的患者和62%接受完整治疗的患者入院ICU。仅接受舒适治疗的患者中有14%得到一个或多个维持生命的治疗，而在接受选择性治疗的患者中有20%。

与完整治疗POLSTs患者相比，仅接受舒适治疗和选择性治疗的患者ICU入院的可能性显著降低。接受仅舒适治疗和选择性治疗的患者中有38%接受了与POLST不一致的治疗。

癌症患者接受POLST不一致治疗的可能性明显低于非癌症患者。痴呆症患者和仅舒适治疗患者接受POLST不一致治疗的可能性显著低于没有痴呆症的患者。因外伤入院的患者更容易接受与POLST不一致的治疗。在选择性治疗的患者中，老年人接受POLST不一致治疗的可能性较低。

总之，在死前6个月内住院的有POLSTs和慢性生命限制性疾病患者中，与完整治疗POLSTs相比，选择性治疗POLSTs与ICU入院率低显著相关。然而，38%的选择性治疗POLST患者接受了与其POLST不一致的重症监护。

附：英文原文

Title: Association of Physician Orders for Life-Sustaining Treatment With ICU Admission Among Patients Hospitalized Near the End of Life

Author: Robert Y. Lee, Lyndia C. Brumback, Seelwan Sathitratanacheewin, William B. Lober, Matthew E. Modes, Ylinne T. Lynch, Corey I. Ambrose, James Sibley, Kelly C. Vranas, Donald R. Sullivan, Ruth A. Engelberg, J. Randall Curtis, Erin K. Kross

Issue&Volume: February 16, 2020

Abstract: Importance  Patients with chronic illness frequently use Physician Orders for Life-Sustaining Treatment (POLST) to document treatment limitations.Objectives  To evaluate the association between POLST order for medical interventions and intensive care unit (ICU) admission for patients hospitalized near the end of life.Design, Setting, and Participants  Retrospective cohort study of patients with POLSTs and with chronic illness who died between January 1, 2010, and December 31, 2017, and were hospitalized 6 months or less before death in a 2-hospital academic health care system.Exposures  POLST order for medical interventions (“comfort measures only” vs “limited additional interventions” vs “full treatment”), age, race/ethnicity, education, days from POLST completion to admission, histories of cancer or dementia, and admission for traumatic injury.Main Outcomes and Measures  The primary outcome was the association between POLST order and ICU admission during the last hospitalization of life; the secondary outcome was receipt of a composite of 4 life-sustaining treatments: mechanical ventilation, vasopressors, dialysis, and cardiopulmonary resuscitation. For evaluating factors associated with POLST-discordant care, the outcome was ICU admission contrary to POLST order for medical interventions during the last hospitalization of life.Results  Among 1818 decedents (mean age, 70.8 [SD, 14.7] years; 41% women), 401 (22%) had POLST orders for comfort measures only, 761 (42%) had orders for limited additional interventions, and 656 (36%) had orders for full treatment. ICU admissions occurred in 31% (95% CI, 26%-35%) of patients with comfort-only orders, 46% (95% CI, 42%-49%) with limited-interventions orders, and 62% (95% CI, 58%-66%) with full-treatment orders. One or more life-sustaining treatments were delivered to 14% (95% CI, 11%-17%) of patients with comfort-only orders and to 20% (95% CI, 17%-23%) of patients with limited-interventions orders. Compared with patients with full-treatment POLSTs, those with comfort-only and limited-interventions orders were significantly less likely to receive ICU admission (comfort only: 123/401 [31%] vs 406/656 [62%], aRR, 0.53 [95% CI, 0.45-0.62]; limited interventions: 349/761 [46%] vs 406/656 [62%], aRR, 0.79 [95% CI, 0.71-0.87]). Across patients with comfort-only and limited-interventions POLSTs, 38% (95% CI, 35%-40%) received POLST-discordant care. Patients with cancer were significantly less likely to receive POLST-discordant care than those without cancer (comfort only: 41/181 [23%] vs 80/220 [36%], aRR, 0.60 [95% CI, 0.43-0.85]; limited interventions: 100/321 [31%] vs 215/440 [49%], aRR, 0.63 [95% CI, 0.51-0.78]). Patients with dementia and comfort-only orders were significantly less likely to receive POLST-discordant care than those without dementia (23/111 [21%] vs 98/290 [34%], aRR, 0.44 [95% CI, 0.29-0.67]). Patients admitted for traumatic injury were significantly more likely to receive POLST-discordant care (comfort only: 29/64 [45%] vs 92/337 [27%], aRR, 1.52 [95% CI, 1.08-2.14]; limited interventions: 51/91 [56%] vs 264/670 [39%], aRR, 1.36 [95% CI, 1.09-1.68]). In patients with limited-interventions orders, older age was significantly associated with less POLST-discordant care (aRR, 0.93 per 10 years [95% CI, 0.88-1.00]).Conclusions and Relevance  Among patients with POLSTs and with chronic life-limiting illness who were hospitalized within 6 months of death, treatment-limiting POLSTs were significantly associated with lower rates of ICU admission compared with full-treatment POLSTs. However, 38% of patients with treatment-limiting POLSTs received intensive care that was potentially discordant with their POLST.

DOI: 10.1001/jama.2019.22523

Source: https://jamanetwork.com/journals/jama/fullarticle/2761227