Relationship of general advance directive instructions to specific life-sustaining treatment preferences in patients with serious illness.

Relationship of general advance directive instructions to specific life-sustaining treatment preferences in patients with serious illness.

OBJECTIVE To determine whether brief general instructions in a typical proxy-instruction advance directive (California Durable Power of Attorney for Health Care [DPAHC]) provide interpretable information about patient requests to limit life-saving treatments, and to determine whether patient treatment preferences are stable over time. DESIGN Prospective structured interviews. SETTING University of California, San Diego Medical Center and Veterans Affairs Medical Center, La Jolla. PATIENTS One hundred four patients (from a randomly chosen sample of 185) with a 5-year life expectancy of no better than 50% as judged by their physicians. MAIN OUTCOME MEASURES Patients completed the California DPAHC, a proxy-instruction advance directive, at entry and at 1 year. The patients also completed a questionnaire at entry, after 6 months, and after 1 year, indicating their preferences on a five-point Likert-format comparative rating scale for cardiopulmonary resuscitation, mechanical ventilation, artificial nutrition, and hospitalization for pneumonia. RESULTS Sixty-eight percent of the subjects executed the DPAHC. Most patients wished treatments to be limited or withheld under certain conditions of reduced quality of life. Although general instructions noted on the DPAHC and preferences regarding specific procedures were stable over the course of a year, the advance directive's general instructions were often inconsistent with, and poor predictors of, specific procedure preferences. CONCLUSIONS The brief general instruction component of the California DPAHC is not helpful in communicating patient wishes regarding specific life-saving procedures.

目的 确定在一份典型的代理指示预立医疗指示（加利福尼亚州医疗保健持久授权书[DPAHC]）中的简要通用指令是否提供了有关患者限制挽救生命治疗的请求的可解释信息，并确定患者的治疗偏好是否随时间稳定。 设计 前瞻性结构化访谈。 地点 加利福尼亚大学圣地亚哥分校医学中心和拉霍亚退伍军人事务医疗中心。 患者 104名患者（从185名随机抽取的样本中选取），经其医生判断，其5年预期寿命不超过50%。 主要观察指标 患者在入组时和1年后完成加利福尼亚州DPAHC（一份代理指示预立医疗指示）。患者还在入组时、6个月后和1年后完成一份问卷，在一个五点利克特式比较评定量表上表明他们对心肺复苏、机械通气、人工营养和肺炎住院的偏好。 结果 68%的受试者签署了DPAHC。大多数患者希望在生活质量下降的某些情况下限制或停止治疗。尽管DPAHC上注明的通用指令以及对特定程序的偏好在一年的过程中是稳定的，但预立医疗指示的通用指令往往与特定程序偏好不一致，且对其预测性差。 结论 加利福尼亚州DPAHC的简要通用指令部分在传达患者对特定挽救生命程序的意愿方面没有帮助。