한빛사논문
- 조회248
Mi-Kyung Song, PhD, RN1; Amita Manatunga, PhD2; Laura Plantinga, PhD3,4; Maureen Metzger, PhD, RN5; Abhijit V. Kshirsagar, MD, MPH6,7; Janice Lea, MD, MSc8; Emaad M. Abdel-Rahman, MD9; Manisha Jhamb, MD, MPH10; Emily Wu, BS2; Jacob Englert, MS2; Sandra E. Ward, PhD, RN11
1Center for Nursing Excellence in Palliative Care, Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia
2Rollins School of Public Health, Emory University, Atlanta, Georgia
3Division of Rheumatology, Department of Medicine, University of California, San Francisco
4Division of Nephrology, Department of Medicine, University of California, San Francisco
5School of Nursing, University of Virginia, Charlottesville
6UNC Kidney Center, University of North Carolina at Chapel Hill School of Medicine
7Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill School of Medicine
8Division of Renal Medicine, Emory University School of Medicine, Emory University, Atlanta, Georgia
9Division of Nephrology, University of Virginia School of Medicine, University of Virginia, Charlottesville
10Division of Renal-Electrolyte, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
11School of Nursing, University of Wisconsin–Madison
Corresponding Author: Mi-Kyung Song, PhD
Abstract
Importance: Evidence of effectiveness of advance care planning (ACP) strategies for patients receiving dialysis and their families is needed.
Objectives: To test the effectiveness of an ACP intervention to prepare patients and their surrogates for end-of-life (EOL) decision-making and to improve surrogate bereavement outcomes.
Design, setting, and participants: This cluster randomized clinical trial, An Effectiveness-Implementation Trial of SPIRIT (Sharing Patients' Illness Representations to Increase Trust) in ESRD, was conducted from December 2017 to March 2023 and included 42 dialysis clinics in 5 US states (Georgia, New Mexico, North Carolina, Pennsylvania, and Virginia) randomized to provide intervention or usual care. Recruitment was from February 15, 2018, to January 31, 2022, and patient-surrogate dyads were followed up for 21 months (until January 17, 2023) or until patient death.
Intervention: Each clinic selected 1 or 2 health care workers (eg, nurse practitioner, registered nurse, or social worker) to conduct 45- to 60-minute ACP discussions with dyads in the clinic or remotely. After March 13, 2020 (commencement of the COVID-19 emergency declaration), all discussions were conducted remotely. An ACP summary was placed in patients' medical records.
Main outcomes and measures: The primary, 2-week preparedness outcomes were dyad congruence on EOL goals of care, patient decisional conflict, surrogate decision-making confidence, and a composite of dyad congruence and surrogate decision-making confidence. Secondary bereavement outcomes were anxiety, depression, and posttraumatic distress 3 months after patient death. To adjust for COVID-19 pandemic effects on bereavement outcomes, a variable to indicate the timing of baseline and 3-month assessment relative to the COVID-19 emergency declaration was created.
Results: Of the 426 dyads enrolled, 231 were in the intervention clinics, and 195 were in the control clinics. Among all dyads, the mean (SD) patient age was 61.9 (12.7) years, and the mean (SD) surrogate age was 53.7 (15.4) years. At 2 weeks, after adjusting for baseline values, dyad congruence (odds ratio [OR], 1.61; 95% CI, 1.12-2.31; P = .001), decisional conflict scores (β, -0.10; 95% CI, -0.13 to -0.07; P < .001), and the composite (OR, 1.57; 95% CI, 1.06-2.34; P = .03) were higher in the intervention group than in the control group. Surrogate decision-making confidence was similar between groups (β, 0.06; 95% CI, -0.01 to 0.13; P = .12). Among 77 bereaved surrogates, after adjusting for baseline values and assessment timing, intervention group anxiety was lower than control group anxiety (β, -1.55; 95% CI, -3.08 to -0.01; P = .05); however, depression (β, -0.18; 95% CI, -2.09 to 1.73; P = .84) and posttraumatic distress (β, -0.96; 95% CI, -7.39 to 5.46; P = .75) were similar.
Conclusions and relevance: In this randomized clinical trial, the ACP intervention implemented by health care workers at dialysis centers improved preparation for EOL decision-making but showed mixed effectiveness on bereavement outcomes. The ACP intervention implemented in dialysis centers may be an effective strategy to the dyad preparation for end-of-life care as opposed to the current focus on advance directives.
논문정보
- Research article
- 2024년 01월 (BRIC 등록일 2024-02-06)
- 국외 연구진
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