Is it recorded in the notes? Documentation of end-of-life care and preferred place to die discussions in the final weeks of life
Is it recorded in the notes? Documentation of end-of-life care and preferred place to die discussions in the final weeks of life
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DOI：
10.1186/1472-684x-10-18
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发表时间：
2011-01-01
影响因子：
3.1
通讯作者：
Seymour, Jane
中科院分区：
文献类型：
--
作者：
Cox, Karen;Moghaddam, Nima;Seymour, Jane
背景：在过去的十年里，人们越来越关注改善临终关怀体验的必要性。一些政策举措已经出台，以制定讨论和记录个人对临终关怀的偏好的方法，特别是首选的死亡地点。方法：目的是调查与患者及其家属讨论和记录生命最后4周的临终关怀和首选死亡地点有关的实践。该研究利用了对65例病例记录的审计，以及对参与姑息治疗提供的卫生保健专业人员的四组访谈。结果：虽然有证据表明，与临终关怀和首选死亡地点有关的讨论发生在大约一半的审计病例笔记中，但似乎缺乏系统的方法来记录与患者或护理人员讨论这些问题。保健工作人员随后强调，发起关于临终关怀和与死亡地点有关的偏好的讨论具有挑战性，而且记录和跟踪这种偏好存在问题。结论：需要进一步开展工作，以确定如何充分记录、修改和在各服务部门之间传递信息，以确保尽可能实现患者对临终关怀和死亡地点的偏好。
Background: Over the past ten years there has been an increasing focus on the need for improving the experience of end of life care. A number of policy initiatives have been introduced to develop approaches to discussing and documenting individual preferences for end of life care, in particular preferred place to die.Methods: The aim was to investigate practice in relation to discussing and documenting end of life care and preferred place to die in the last 4 weeks of life with patients and their families. The study utilised an audit of 65 case notes, alongside four group interviews with a mix of health care professionals involved in palliative care provision.Results: While there was evidence that discussions relating to end of life care and preferred place to die had taken place in around half of the audited case notes, there appeared to be a lack of a systematic approach to the recording of discussions with patients or carers about these kind of issues. Health care staff subsequently highlighted that initiating discussions about end of life care and preferences in relation to place of death was challenging and that the recording and tracking of such preferences was problematic.Conclusions: Further work is required to establish how information may be adequately recorded, revised and transferred across services to ensure that patients' preferences in relation to end of life care and place of death are, as far as possible, achieved.