■改善重症监护病房(ICU)的临终关怀是当务之急,但是很少发现临床上可改变的死亡和死亡质量(QODD)因素。
■为了全面识别与垂死的ICU患者QODD等级相关的因素,基于与丧亲结局相关因素的综合框架,强调临床上可改变的因素。
这项观察性队列研究于2018年1月至2020年3月在2个台湾医疗中心的医疗ICU进行,随访至2022年12月。符合条件的参与者包括主要的家庭代理人,他们负责决定ICU重症患者的高死亡风险(急性生理学和慢性健康评估II评分>20),但在ICU入院后存活超过3天。数据分析于2023年7月至9月进行。
■QODD通过23项ICU-QODD问卷进行测量。与4个先前确定的QODD类别中的患者成员资格相关的因素(高,中度,贫穷到不确定,和最差)使用3步方法对潜在类建模进行检查,其中高QODD类作为参考类别。
■总共309个家庭代理人(平均[SD]年龄,49.83[12.55]岁;184名女性[59.5%]和125名男性[40.5%])被纳入研究。在所有代理人中,91名(29.4%)是患者的配偶,66名(53.7%)是患者的成年子女。患者人口统计学与QODD等级无关。两个家庭人口统计数据(年龄和性别),与患者(配偶或成年子女)的关系,ICU住院时间与QODD等级相关。代孕患者感知到更大的社会支持不太可能在穷人到不确定(调整后的优势比[aOR],0.89;95%CI,0.83-0.94)和最差(AOR,0.92;95%CI,0.87-0.96)QODD类。家庭会议与穷人到不确定的QODD类(aOR,8.61;95%CI,2.49-29.74)和最差QODD等级(aOR,7.28;95%CI,1.37-38.71)。心肺复苏死亡与最差QODD等级相关(aOR,7.51;95%CI,1.12-50.25)。患者死亡时的家庭存在与中度QODD等级一致呈负相关(aOR,0.16;95%CI,0.05-0.54),差到不确定的QODD类(AOR,0.21;95%CI,0.05-0.82),和最差的QODD类(AOR,0.08;95%CI,0.02-0.38)。较高的家庭对ICU护理的满意度与穷人到不确定的QODD等级呈负相关(aOR,0.93;95%CI,0.87-0.98)和最差QODD等级(aOR,0.86;95%CI,0.81-0.92)。
■在这项针对危重患者及其家庭代孕的队列研究中,与不可变家庭人口统计相比,可改变的生命末期ICU护理特征在与患者QODD类的关联中发挥了更重要的作用,预先存在的家庭健康状况,患者人口统计学,和患者的临床特征,从而照亮可行的机会,以改善生命结束ICU护理。
UNASSIGNED: Improving end-of-life care in the intensive care unit (ICU) is a priority, but clinically modifiable factors of quality of dying and death (QODD) are seldom identified.
UNASSIGNED: To comprehensively identify factors associated with QODD classes of dying ICU patients, emphasizing clinically modifiable factors based on the integrative framework of factors associated with for bereavement outcomes.
UNASSIGNED: This observational cohort study was conducted at medical ICUs of 2 Taiwanese medical centers from January 2018 to March 2020 with follow-up through December 2022. Eligible participants included primary family surrogates responsible for decision making for critically ill ICU patients at high risk of death (Acute Physiology and Chronic Health Evaluation II score >20) but who survived more than 3 days after ICU admission. Data analysis was conducted from July to September 2023.
UNASSIGNED: QODD was measured by the 23-item ICU-QODD questionnaire. Factors associated with patient membership in 4 previously determined QODD classes (high, moderate, poor to uncertain, and worst) were examined using a 3-step approach for latent class modeling with the high QODD class as the reference category.
UNASSIGNED: A total of 309 family surrogates (mean [SD] age, 49.83 [12.55] years; 184 women [59.5%] and 125 men [40.5%]) were included in the study. Of all surrogates, 91 (29.4%) were the patients\' spouse and 66 (53.7%) were the patients\' adult child. Patient demographics were not associated with QODD class. Two family demographics (age and gender), relationship with the patient (spousal or adult-child), and length of ICU stay were associated with QODD classes. Patients of surrogates perceiving greater social support were less likely to be in the poor to uncertain (adjusted odds ratio [aOR], 0.89; 95% CI, 0.83-0.94) and worst (aOR, 0.92; 95% CI, 0.87-0.96) QODD classes. Family meetings were associated with the poor to uncertain QODD class (aOR, 8.61; 95% CI, 2.49-29.74) and worst QODD class (aOR, 7.28; 95% CI, 1.37-38.71). Death with cardiopulmonary resuscitation was associated with the worst QODD class (aOR, 7.51; 95% CI, 1.12-50.25). Family presence at patient death was uniformly negatively associated with the moderate QODD class (aOR, 0.16; 95% CI, 0.05-0.54), poor to uncertain QODD class (aOR, 0.21; 95% CI, 0.05-0.82), and worst QODD class (aOR, 0.08; 95% CI, 0.02-0.38). Higher family satisfaction with ICU care was negatively associated with the poor to uncertain QODD class (aOR, 0.93; 95% CI, 0.87-0.98) and worst QODD class (aOR, 0.86; 95% CI, 0.81-0.92).
UNASSIGNED: In this cohort study of critically ill patients and their family surrogates, modifiable end-of-life ICU-care characteristics played a more significant role in associations with patient QODD class than did immutable family demographics, preexisting family health conditions, patient demographics, and patient clinical characteristics, thereby illuminating actionable opportunities to improve end-of-life ICU care.