本文由小咖机器人翻译整理

期刊来源：JAMA

原文链接：https://doi.org/10.1001/jama.2023.25092

摘要内容如下：

重要性

增加住院病人的姑息治疗服务是优先考虑的，但缺乏其有效性的大规模实验证据。

目的

确定在不需要更多姑息治疗人员的情况下，为重病住院患者默认安排姑息治疗咨询是否会增加咨询并改善结果。

设计、设置和参与者

2016年3月21日至2018年11月14日，在11家美国医院收治的65岁或以上的晚期慢性阻塞性肺病、痴呆或肾衰竭患者中，进行了一项实用的阶梯式楔形整群随机试验。结果数据收集于2019年1月31日结束。

干预

为符合条件的患者默认安排姑息治疗咨询，同时允许临床医生选择退出，并与常规护理进行比较，在常规护理中，临床医生可以选择安排姑息治疗。

主要成果和措施

主要终点是住院时间，死亡编码为最长住院时间，次要终点包括姑息治疗就诊率、出院到临终关怀中心、不复苏医嘱和住院死亡率。

结果

在入选的34239名患者中，24065名患者的住院时间至少为72小时，并被纳入主要分析样本（10313名患者被纳入默认顺序组，13752名患者被纳入常规护理组；女性13338人，占55.4%；平均年龄77.9岁）。默认医嘱组的患者接受姑息治疗咨询的比例高于标准护理组（43.9%比16.6%；调整后的比值比[AOR]，5.17[95%CI，4.59-5.81]）和更早接受咨询（入院后平均[SD]3.4[2.6]天vs 4.6[4.8]天；P<.001）。住院时间在默认顺序和常规护理组之间没有差异（中位住院时间的百分比差异，-0.53%[95%CI，-3.51%至2.53%]）。与常规护理组相比，默认医嘱组患者出院时的不复苏医嘱（AOR，1.40[95%CI，1.21-1.63]）和出院后到临终关怀（AOR，1.30[95%CI，1.07-1.57]）的发生率较高，住院死亡率相似（4.7%vs 4.2%；AOR，0.86[95%CI，0.68-1.08]）。

结论和相关性

默认的姑息治疗会诊医嘱并没有缩短患有晚期慢性疾病的老年住院患者的住院时间，但确实改善了会诊和一些临终护理流程的比率和时间。

试用注册

ClinicalTrials.gov标识符：NCT02505035。

英文原文如下：

Abstracts

Importance  Increasing inpatient palliative care delivery is prioritized, but large-scale, experimental evidence of its effectiveness is lacking.

Objective  To determine whether ordering palliative care consultation by default for seriously ill hospitalized patients without requiring greater palliative care staffing increased consultations and improved outcomes.

Design, Setting, and Participants  A pragmatic, stepped-wedge, cluster randomized trial was conducted among patients 65 years or older with advanced chronic obstructive pulmonary disease, dementia, or kidney failure admitted from March 21, 2016, through November 14, 2018, to 11 US hospitals. Outcome data collection ended on January 31, 2019.

Intervention  Ordering palliative care consultation by default for eligible patients, while allowing clinicians to opt-out, was compared with usual care, in which clinicians could choose to order palliative care.

Main Outcomes and Measures  The primary outcome was hospital length of stay, with deaths coded as the longest length of stay, and secondary end points included palliative care consult rate, discharge to hospice, do-not-resuscitate orders, and in-hospital mortality.

Results  Of 34 239 patients enrolled, 24 065 had lengths of stay of at least 72 hours and were included in the primary analytic sample (10 313 in the default order group and 13 752 in the usual care group; 13 338 [55.4%] women; mean age, 77.9 years). A higher percentage of patients in the default order group received palliative care consultation than in the standard care group (43.9% vs 16.6%; adjusted odds ratio [aOR], 5.17 [95% CI, 4.59-5.81]) and received consultation earlier (mean [SD] of 3.4 [2.6] days after admission vs 4.6 [4.8] days; P < .001). Length of stay did not differ between the default order and usual care groups (percent difference in median length of stay, -0.53% [95% CI, -3.51% to 2.53%]). Patients in the default order group had higher rates of do-not-resuscitate orders at discharge (aOR, 1.40 [95% CI, 1.21-1.63]) and discharge to hospice (aOR, 1.30 [95% CI, 1.07-1.57]) than the usual care group, and similar in-hospital mortality (4.7% vs 4.2%; aOR, 0.86 [95% CI, 0.68-1.08]).

Conclusions and Relevance  Default palliative care consult orders did not reduce length of stay for older, hospitalized patients with advanced chronic illnesses, but did improve the rate and timing of consultation and some end-of-life care processes.

Trial Registration  ClinicalTrials.gov Identifier: NCT02505035.

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