Why don't patients and physicians talk about end-of-life care?: Barriers to communication for patients with acquired immunodeficiency syndrome and their primary care clinicians
Why don't patients and physicians talk about end-of-life care?: Barriers to communication for patients with acquired immunodeficiency syndrome and their primary care clinicians
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DOI：
10.1001/archinte.160.11.1690
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发表时间：
2000-06-12
影响因子：
--
通讯作者：
Collier, AC
中科院分区：
文献类型：
--
作者：
Curtis, JR;Patrick, DL;Collier, AC
背景：患有慢性和晚期疾病的患者经常不与他们的医生谈论临终关怀。改善这种交流的干预措施通常是不成功的，这表明这种交流必须存在重要的障碍。目的：确定临终关怀患者与临床沟通的障碍和促进因素，并确定在最不可能讨论临终关怀的患者中更常见的障碍和促进因素：少数民族和注射吸毒者。方法：我们从大学和私人诊所招募了57例晚期获得性免疫缺陷综合征患者及其初级保健临床医生进行了一项前瞻性研究。从先前的定性研究中确定了临终沟通的障碍和促进因素，并评估了频率和重要性以及与临终沟通的发生和质量的关联。结果：临床医生比患者发现了更多的障碍。患者和临床医生确定的障碍分为三类潜在的干预措施：关于临终关怀的教育，帮助解决临终关怀问题的咨询，以及促进患者-临床沟通的医疗保健系统改革。尽管患者认为的障碍中没有一个与交流有关，但有两个临床医生认为的障碍与交流较少有关：“患者还没有病得很重”和“患者还没有准备好谈论临终关怀”。非白人患者比白人患者更容易识别出以下两个障碍：“我觉得如果我谈论死亡，可能会让死亡离我更近”和“如果我病得很重，我不喜欢谈论我想要的治疗。”结论：与获得性免疫缺陷综合征患者及其临床医生相关的障碍和促进因素的多样性表明，改善临终关怀沟通的干预措施必须关注个人需求，除了教育之外，还必须包括咨询干预和卫生系统改革。与患者障碍相比，临床医生障碍更常见，与临终沟通的发生也更密切相关，这表明临床医生是改善临终沟通的重要目标群体。
Background: Patients with chronic and terminal disease frequently do not talk to their physicians about end-of-life care. Interventions to improve this communication have generally been unsuccessful, suggesting that important barriers to this communication must exist.Objectives: To determine the barriers to and facilitators of patient-clinician communication about end-of-life care and to identify barriers and facilitators that are more common among those patients who are least likely to discuss end-of-life care: minorities and injection drug users.Methods: We conducted a prospective study of 57 patients with advanced acquired immunodeficiency syndrome and their primary care clinicians who were recruited from university and private clinics. Barriers to and facilitators of end-of-life communication were identified from a prior qualitative study and assessed for frequency and importance and for an association with the occurrence and quality of end-of-life communication.Results: Clinicians identified more barriers than patients. Barriers identified by patients and clinicians fell into 3 categories of potential interventions: education about end-of-life care, counseling to help address end- of-life concerns, and health care system changes to facilitate patient-clinician communication. Although none of the patient-identified barriers was associated with the occurrence of communication, 2 clinician-identified barriers were associated with less communication: "the patient has not been very sick yet" and "the patient isn't ready to talk about end-of-life care." Nonwhite patients were more likely to identify the following 2 barriers than white patients: "I feel that if I talk about death, it could bring death closer" and "I don't like to talk about the care I want if I get very sick."Conclusions: The diversity of barriers and facilitators relevant to patients with acquired immunodeficiency syndrome and their clinicians suggests that interventions to improve communication about end-of-life care must be focused on individual needs and must involve counseling interventions and health system changes in addition to education. Clinician barriers are more common and more strongly associated with the occurrence of end-of-life communication than patient barriers, suggesting that clinicians are an important target group for improving this communication.