预先指示的国内外发展现状

归纳预先指示相关概念,总结国内外发展现状及评估工具,分析预先指示在我国推广的影响因素,为预先指示在我国医疗实践中的推广提供一定有益参考.     

生前预嘱的产生和应用现状

生前预嘱(living will)是人们事先,也就是在健康或意识清楚时签署的,说明在不可治愈的伤病末期或临终时要或不要哪种医疗护理的指示文件.大多数人对于死亡和濒死的态度可能非常强烈和个性化,有些人对于由机器来维持生命感到恐惧.另一些人,即使通过一些痛苦的方式来维持,也希望尽量多活一些时间.生前预嘱尊重患者的医疗自主权.强调了医护人员和患者及家属之间在医疗工作中的合作关系,是医学领域中必要的创新.     

基于CiteSpace对我国预立医疗照护计划研究热点的可视化分析

目的:分析近10年预立医疗照护计划(ACP)研究热点,为我国推进ACP事业提供借鉴与帮助。方法:采用CiteSpace软件对2013年1月1日—2023年4月30日收录于中国知网(CNKI)中ACP相关文献进行可视化分析。结果:ACP研究发文量总体呈上升趋势,形成以邓仁丽、李嘉音为核心的作者合作群,研究机构以郑州大学护理与健康学院发文最多(12篇)。该领域的研究热点归纳为3个方面：研究方式主要是质性研究;研究对象聚焦于晚期癌症病人及老年人;研究内容主要是病人ACP准备度、医护人员对ACP的认知与实践、缓和医疗事业、影响因素。结论:ACP研究在国内护理领域发文量整体呈增长趋势,但研究机构和作者合作较为薄弱,提示今后应加强合作,对研究热点及研究前沿进行深入挖掘,改善终末期病人生命质量。     

医护人员对预先指示的态度及其影响因素分析

目的：调查临床医护人员对预先指示的态度并分析其影响因素,为有针对性地在临床医护人员中推广预先指示观念提供依据。方法：采用分层抽样与方便抽样相结合的方法,对郑州市不同等级医疗机构的298名一线医护人员进行问卷调查,采用logistic回归分析筛选医护人员预先指示态度的影响因素。结果：86.6%的医护人员支持使用预先指示,子女情况、患者家属因素（曾遇到患者家属因治疗措施争执）、患者自主权、促进安乐死的应用、有被滥用的可能（患者可能被迫签署及医生会忽视病情）、医护人员主观因素（工作中情感负担过重、讨论预先指示显得冷漠麻木及应尽可能延长患者生命）等为预先指示态度的影响因素。结论：医护人员对预先指示的态度受多种因素影响,应采取针对性措施对医护人员、患者及家属进行教育,为预先指示的应用做好准备。     

我国肺结核10年文献计量学分析

目的利用文献计量学原理揭示我国肺结核研究现状。方法选用中国生物文献数据库（CBMdisc）为数据源,检索2000年以来我国发表的肺结核文献,采用Foxpro6.0编程处理数据,对年代、作者、机构及主题分布进行文献计量学分析。结果我国肺结核文献呈增长趋势,发文单位主要分布在广州市胸科医院、北京市结核病胸部肿瘤研究所、上海市肺科医院、郑州河南省胸科医院及山东省胸科医院等,省市主要分布在山东、广东及河南等。研究热点主题分布在相关疾病、诊断、药物治疗、流行病4个方面。《临床肺科杂志》、《中国防痨杂志》及《中国误诊学杂志》等8种杂志刊登了肺结核文献发文的19.81%（3173篇）。结论随着我国不断增强与国际组织的合作,社会不断发展和基层结核病防治网络的不断加强,以及2001年起结核病控制策略（DOTS策略）的逐步推广,肺结核病的研究已达到了较高水平。     

我国急危重症患者转运的文献计量学分析

目的 对我国急危重症患者转运相关文献进行文献计量学分析,为开展相关研究以及制订政策提供参考依据.方法 检索我国中文期刊数据库(SinoMed、CNKI和万方数据)收录的自2009年至今已发表的文献,应用文献计量学方法进行统计分析.结果 共纳入2671篇文献,自2009年起至今年发文量总体有上升趋势,经济发达地区发文量较...     

我国护理网络教育的文献计量学分析

目的从文献计量学的角度分析我国护理领域网络教育研究现状、热点、趋势及存在问题。方法从中国知网期刊全文数据库、万方、维普和中国生物医学文献数据库检索并筛选自建库至2018年4月20日护理网络教育相关学术论文,采用CiteSpace 5.3.R1软件对文献特征进行分析。结果共纳入文献1 902篇,文献数量呈逐年递增趋势,研究机构分布呈现东部数量多于西部,以同一第一作者最大发文量5篇,研究方向偏向于网络教育适用性,我国当前的研究热点集中于网络教育的应用、信息素养、网络资源的建立与需求状况。结论我国护理网络教育正处于探索阶段,文献质量不高,尚未形成成熟的科研团队和研究体系,有关理论研究发展不平衡,研究热点集中,同时存在地区差异。     

我国延续护理研究现状的文献计量学分析

目的 :应用文献计量学方法分析我国延续护理的研究现状及其存在问题,为今后该领域的研究提供参考。方法 :通过中国期刊全文数据库和万方数据库检索我国11种护理核心期刊上发表的延续护理的相关文献并进行计量分析。结果 :共检出318篇有效文献,发文数量从2007年开始呈上升趋势;文献主要来源于广东、江苏、北京等经济较发达地区;大部分文献成果来自于医院;基金论文所占比例为34.59%;研究内容主要集中在延续护理的应用与效果观察方面(66.04%);延续护理方式位于前三位的为电话、短信随访,家庭访视和网络信息平台;评价指标以患者功能和临床结果指标为主。结论 :近年来,我国延续护理发展迅速,日益受到重视,但研究质量有待提高,研究的深度及广度不够,在实施过程中缺乏多学科团队共同协作,服务存在不规范性和随意性,今后可发挥网络信息平台优势,采用多种形式相结合的服务方式,加强各大医院与社区卫生服务机构的联系,建立医院-社区-家庭服务模式。     

我国护理精细化管理的文献计量学分析

目的 对国内护理精细化管理的文献进行文献计量学分析,明确目前存在的问题,为护理学研究提供借鉴.方法 检索中国生物医学文献数据库、中国期刊网数据库、万方数据库和维普数据库中护理精细化管理的相关文献,利用NoteExpress 2.0和Excel软件对文献进行文献计量学分析.结果 共纳入364篇文献,相关文献的发文量呈现逐年上升趋势;吉林、广东、湖北等10个地区发文较多,共186篇,占总发文量的51.10％;收录文献较多的期刊为《医学信息》、《护理研究》和《中国卫生产业》,3种期刊共收录文献53篇(15.32％);文献类型主要为经验介绍类和类实验性研究类,共298篇(81.87％);文献合作度为2.15;有8篇文献获得资金资助.结论 近年来护理精细化管理逐渐受到研究者的关注,研究者应加强机构间的合作,同时注重提高研究设计的严谨性,以促进护理精细化管理的进一步发展.     

Use of advance care directives for individuals with dementia living in residential accommodation: A descriptive survey

BackgroundEnd-of-life decision-making for individuals living with a dementia needs to be addressed because as dementia progresses, individuals need support to make decisions about their health care, living arrangements and end-of-life care changes. Advance care directives (ACDs) provide an opportunity for individuals living with a dementia to communicate their wishes about these important issues.AimThe aim of this study was to understand how Australian registered nurses (RNs) use ACDs for individuals with a dementia living in residential accommodation.MethodsTwo hundred and thirty eight RNs working in Australian residential accommodation were recruited via social media, professional organisations and organisations providing residential accomodation. Respondents completed an online survey delivered via Survey Monkey.Findings59.7% of respondents reported commencing discussions around ACDs within the first month of individuals living with a dementia relocating to residential accommodation. However, 42.4% never or rarely completed ACDs. Only 59.3% stated that ACDs for individuals living with a dementia were always or often regularly reviewed. 53.8% identified that ACDs were always adhered to when an individuals’ circumstances changed. 62.6% felt that understanding among families about ACDs was sometimes, or often, a barrier to using ACDs.ConclusionThe implementation of ACDs in Australian residential accommodation for those living with a dementia remains sub-optimal. This study has demonstrated that ACD documentation and policies describing how they should be used exist, but gaps remain around the practical implementation of ACDs. Strategies to promote communication and collaboration between residential facilities, general practitioners and carers / families could also assist in providing cohesive, high quality care.     

An exploration of decision-making factors regarding advance directives in a long-term care facility

PURPOSE: To explore the experiences of residents who had signed an advance directive on admission to a long-term care facility and apply the Advance Directive Decision-Making Model to this process. DATA SOURCES: Interactive interviews with 13 elders. Questions related to how each felt about their life and death, how each perceived the advance directive discussion, and what factors influenced their decisions were discussed. CONCLUSIONS: The thematic analysis suggested that the decision regarding advance directives was multifaceted and complex. It required preparation, understanding, and time. Decision-making ability was sometimes compromised by the other stressors associated with the move to a long-term care facility. IMPLICATIONS FOR PRACTICE: Nurse practitioners will have an easier time discussing medical conditions and choices regarding end-of-life care with residents and their families if advance directives are discussed thoroughly on admission to a long-term care facility and are updated routinely.     

Patients' understanding of advance directives and cardiopulmonary resuscitation

OBJECTIVE: To describe understanding of end-of-life issues and compare characteristics of patients with and without advance directives. SETTING: A 325-bed community teaching hospital. MEASUREMENTS: Questionnaires were administered to all patients admitted to the medical-surgical wards. RESULTS: Of 755 patients admitted during the study period, 264 patients participated in the study, and 82 (31%) had living wills. Patients with living wills were more likely to be white, Protestant, and highly educated. Most (76%) created them with a lawyer or family member, whereas only 7% involved physicians. Although these patients were able to identify some components of cardiopulmonary resuscitation (CPR), few (19%) understood the prognosis after CPR. After explaining CPR, 37% of those with living wills did not want it, which was not stated in their directive or hospital record. If life-sustaining therapies were already started, 39% of these patients stated that they would not want CPR or mechanical ventilation if the likelihood of recovery was < or =10%. Patients without living wills either had not heard (18%) or did not know enough (51%) about them. After education, 5% did not want CPR, and 32% would terminate life-sustaining therapies if the likelihood of recovery was < or =10%. Seventy percent of these patients expressed interest in creating a living will. CONCLUSIONS: Patients with living wills understand poorly "life-sustaining therapies" and the implications of their advance directives. Most fail to involve physicians in creating directives. A significant number of those without living wills have end-of-life wishes that could be addressed by and appear open to the idea of creating advance directives.     

对霍奇金淋巴瘤患者和家属预先指示认知一致性的研究

目的调查霍奇金淋巴瘤(HL)患者和家属对预先指示(Ads)认知的一致性,分析患者和家属Ads认知的影响因素。方法采用便利抽样法,选取2017年1月—2018年12月于郑州大学第一附属医院收治的HL患者107例及1∶1配对家属107名,收集患者和家属的一般资料及患者临床特征情况,采用Kappa检验分析患者与患者家属对Ads认知的一致性,采用单因素和多因素分析患者和患者家属Ads认知的影响因素。结果愿意制定Ads的HL患者占66.36%(71/107),高于能够遵守患者Ads意愿的家属比例46.72%(50/107),差异有统计学意义(χ2=8.387,P=0.004),Kappa值为0.222,HL患者及家属Ads认知的一致性较差。Logistic回归分析显示,年龄、宗教信仰、丧亲经历、全身症状和美国东部肿瘤协作组体力状况评分是HL患者制定Ads意愿的影响因素,而宗教信仰和丧亲经历是患者家属遵循患者Ads意愿态度的影响因素。结论HL患者及家属对Ads认知存在差异,家属对Ads的选择不能完全代表患者本人;宗教信仰和丧亲经历是HL患者及家属Ads认知共同的影响因素。     

Communication through advance directives

There are two kinds of justifications for advance directives. The first is that they extend patient autonomy into the future, allowing individuals to control or at least influence their care after they have lost the capacity to make decisions. The second is that they help physicians and family members make emotionally stressful decisions in difficult circumstances. Whether directives are written or unwritten is of secondary importance. The primary concern is that they are based on an adequate understanding of medical options. Two cases illustrate the relative importance of these features of advance directives.     

Using the stages of change model to improve communication about advance care planning

TOPIC: Advance care planning (ACP) is a term intended to describe the dynamic process of discussing wishes for future medical care. PURPOSE: To demonstrate how a behavior change model can be used to enhance ACP. SOURCES: Authors' personal experience, workshops, literature review. CONCLUSIONS: Incorporating behavioral change theory helps develop workable interventions and provides strategies for nurses to approach patients appropriately about planning for future medical care.     

Randomized study of stability and change in patients' advance directives

Little is known about ethnic differences in understanding or using advance directives (ADs). Although health practitioners may presume AD intentions are durable over time, there is no supporting evidence. This randomized study intended to (a) examine differences between hospitalized Hispanic and non-Hispanic patients' AD preferences, (b) assess AD stability, and (c) discover if the Life Support Preferences Questionnaire (LSPQ) influences AD preferences. Hispanics and non-Hispanics showed no difference in AD preferences. However, non-Hispanics were more likely to change AD preferences. The LSPQ itself prompted change in AD preferences, delivering an educational effect with no specific educational intent. Change seen in patients' ADs, even over a brief interval, suggests revisiting AD preferences with patients and their families after hospitalization.     

Advance directives Good,bad or indifferent

The author writes about various alternatives once decisional capacity is lost. So-called advance directives come in two forms: the living will and an appointed proxy for health care. The US--were these have been legally binding for over 20 years in all states--is a useful laboratory for studying the effect. Advantages and disadvantages are discussed. In some civilizations decisions about all such matters are made in different ways--these are not superior or inferior but simply different. In the US with its shameful social conditions for a large part of the population more important problems need to be addressed. In civilizations which have at least basic medical care for all, discussing such documents becomes far more important. The EU is likely to make some form of advance directive have legal standing. The last 20 or more years that they have been utilized in the US may provide experience important for the time when the EU also makes such documents legally binding.     

Advance directives and mortality rates among nursing home residents in Taiwan: A retrospective,longitudinal study

BackgroundNo data-based evidence is available regarding the best time for nursing home nurses to obtain residents’ signatures on advance directives, especially for do-not-resuscitate directives, the most common type of advance directive. This information is needed to enhance the low prevalence of advance directives in Asian countries.ObjectivesThe purposes of this study were to understand (1) the timing between nursing home admission and signing a do-not-resuscitate directive, (2) the factors related to having a do-not-resuscitate directive, and (3) the association between having a do-not-resuscitate directive and nursing home residents’ mortality in Taiwan.DesignRetrospective, longitudinal design.SettingSix nursing homes in Taiwan.ParticipantsNursing home residents (N = 563).MethodsData were collected by retrospective chart review with 1-year follow-up. Factors related to having a do-not-resuscitate directive were analyzed by multiple logistic regression, while associations between signing a do-not-resuscitate directive (resuscitation preference) and mortality were examined by Cox proportional hazard regression models.ResultsThe mean interval between nursing home admission and signing a do-not-resuscitate directive was 840.65 days (2.30 years), which was longer than the time from admission to first transfer to hospital (742.4 days). Having a do-not-resuscitate directive was related to whether the resident had a nasogastric tube (odds = 2.57) and the number of transfers to hospital (odds = 1.18). Among the 563 residents, 55 (9.77%) had died at the 1-year follow-up. Having a do-not-resuscitate directive was associated with a greater risk of death (unadjusted hazard ratio, 2.03; 95% confidence interval, 1.10–3.98; p = 0.02), but this risk did not persist after adjusting for age (hazard ratio, 1.89; 95% confidence interval, 0.99–3.59; p = 0.05).ConclusionEarly research recommendations to sign an advance directive, particularly a do-not-resuscitate order, on nursing home admission may not be the best time for Chinese nursing home residents. Our results suggest that the best time to sign a do-not-resuscitate directive is as early as possible and no later than 2 years (742 days) after admission if residents had not already done so. Residents on nasogastric tube feeding should be particularly targeted for discussions about do-not-resuscitate directives.     

Current legal status of advance directives in the United States

Advance directive legislation has been in place throughout much of the United States for nearly 3 decades. The right to give an informed consent to or refusal of medical treatment has been recognized by state and federal courts, and that right has been determined to survive the loss of decisional capacity and may be exercised through the execution of instructional or proxy directives. Despite these developments, the percentage of the adult population with a formal advance directive of any type has never exceeded 15%. Moreover, a remarkable number of these directives are ambiguous and/or their existence is unknown to the physicians who are expected to rely upon them. Even unambiguous directives may not be followed at the critical stage in the trajectory of a patient's illness, and the accountability for such disregard by health care institutions or professionals is negligible to nonexistent. Nevertheless, there is real potential for advance directives, as a key element to sound advance care planning, to fulfill their initial promise as instruments of the prospective autonomy of patients. In order for that potential to be realized, primary care physicians must embrace advance care planning as a part of their professional responsibility to patients.