社区老年慢性病患者预先指示接受度及影响因素研究

背景　随着老龄化进程不断加快，我国老年慢性病患者逐年增多，因急慢性并发症的发生发展，其医疗事务的沟通决策能力将受到严重影响。因此提前进行老年慢性病患者的医疗照护规划与需求表达十分必要。目的　调查社区老年慢性病患者对预立医疗照护计划（advance care planning，ACP）实施偏好，并分析其影响因素。方法　于2019年10月-2020年1月，采用便利抽样法抽取锦州市社区老年慢性病患者280例为调查对象。采用一般资料问卷、老年人死亡态度量表、改良Barthel指数评定量表、ACP接受程度调查问卷对其进行问卷调查。采用多重线性逐步回归分析影响社区老年慢性病患者ACP接受度的因素。结果　回收有效问卷271份，有效回收率为96.8%。社区老年慢性病患者死亡态度总分为（73.42±12.96）分，日常生活活动能力总分为（83.99±21.07）分，社区老年慢性病患者ACP接受度总分为（66.20±8.31）分。老年人死亡态度中逃离导向的死亡接受维度（r=-0.206，P<0.001）、死亡逃避维度（r=-0.260，P<0.001）与ACP接受度呈负相关，自然接受维度（r=0.303，P<0.001）与ACP接受度呈正相关；日常生活活动能力（r=-0.361，P<0.001）与ACP接受度呈负相关。多重线性逐步回归分析结果显示，ACP接受度=73.740+1.602×文化程度-0.234×逃离导向的死亡接受+0.673×自然接受-0.403×死亡逃避-0.141×日常生活活动能力。结论　社区老年慢性病患者ACP接受程度整体呈中等偏上水平，死亡态度和日常生活活动能力是影响其ACP接受度的重要因素。社区医务工作者除向来诊的老年慢性病患者提供医疗卫生服务外，还应以口头沟通、宣传手册和海报等多种形式介绍ACP的相关知识，以提高老年慢性病患者对ACP的整体认知；居委会及社会工作团体可在老年慢性病患者中定期开展死亡教育和临终关怀的相关知识讲座，使老年慢性病患者抱有积极的死亡态度及对临终关怀的有效理解，进而提高老年慢性病患者对ACP的接受程度。

Acceptance of Advance Directives and Influencing Factors among Elderly Patients with Chronic Diseases in the Community

Background　The prevalence of chronic disease in the elderly is increasing with the accelerating process of aging in China. The development of short- and long-term complications of chronic diseases，may seriously affect these patients' ability of communication and decision-making in medical affairs. Therefore，it is essential for them to timely make an advance care plan to state their needs clearly. Objective　To investigate the preference and influencing factors of making an advance care plan in community-dwelling elderly patients with chronic diseases. Methods　From October 2019 to January 2020，280 community-dwelling elderly chronic disease patients were selected from Jinzhou by convenient sampling method. The Demographic Data Questionnaire developed by our research group，Elderly Death Attitude Scale（EDAS），Modified Barthel Index and Patient's Advance Care Planning Acceptance（PACP） Questionnaire were used to investigate them. Multiple linear regression analysis was used to analyze the factors associated with the acceptance of advance care planning. Results　271 valid questionnaires were collected，and the effective recovery rate was 96.8%. The average scores of EDAS，activities of daily living and PACP in the respondents were （73.42±12.96），（83.99±21.07） and（66.20±8.31），respectively. Escape-oriented death acceptance dimension（r=-0.206，P<0.001） and death escape dimension（r=-0.260，P<0.001） were negatively correlated with ACP acceptance，while natural acceptance dimension（r=0.303，P<0.001） was positively correlated with ACP acceptance. Activities of daily living（r=-0.361，P<0.001） was negatively correlated with ACP acceptance. Multiple linear regression analysis showed that the acceptance of ACP was 73.740 + 1.602 × education level-0.234 × escape-oriented death acceptance + 0.673 × natural acceptance-0.403 × death escape-0.141 × activities of daily living. Conclusion　The acceptance of ACP in elderly patients with chronic diseases in community was above the middle level. Death attitude and activities of daily living were the important factors influencing the acceptance of ACP. In addition to providing medical and health services to elderly patients with chronic diseases，community medical workers should also give them ACP-related health education via oral form，brochures and posters to improve their overall awareness of ACP. Neighborhood committees and social work groups can regularly give lectures on death education and hospice care to these patients to make them have a positive attitude towards death and an effective understanding of hospice care，thereby improving their acceptance of ACP.