Is shared decision-making vanishing at the end-of-life? A descriptive and qualitative study of advanced cancer patients' involvement in specific therapies decision-making.
Is shared decision-making vanishing at the end-of-life? A descriptive and qualitative study of advanced cancer patients' involvement in specific therapies decision-making.
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DOI：
10.1186/s12904-015-0057-4
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发表时间：
2015-11-16
影响因子：
3.1
通讯作者：
Aubry R
中科院分区：
文献类型：
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作者：
Beaussant Y;Mathieu-Nicot F;Pazart L;Tournigand C;Daneault S;Cretin E;Godard-Marceau A;Chassagne A;Trimaille H;Bouleuc C;Cuynet P;Deconinck E;Aubry R
对于肿瘤医生和晚期癌症患者在面临是否继续、限制或停止特定治疗这一问题时，在主观层面所面临的利害关系，我们知之甚少。我们研究了（1）此类问题出现的频率，以及（2）从医生和患者的角度来看决策过程的主观决定因素。
（1）在五家机构的肿瘤科和/或血液科病房，对所有住院患者进行了为期一周的筛查。我们纳入了那些晚期癌症患者，对他们提出了关于继续、限制或停止特定治疗（QST）的问题。（2）定性设计基于深度访谈。
在常规病房，在研究期间，12.8%的癌症患者（202名中的26名）涉及QST。对所有医生和21名晚期癌症患者进行了访谈。当医生估计患者预期寿命在15天到3个月之间时，最常出现此类问题。面对最常见的困境（风险 - 收益平衡不确定），医生表现出不同的让患者参与的方式。前两种被称为“无选择”模式：1）试图通过技术答案或“观望”态度来解决困境，而不是让患者参与问题探讨和思考；2）在“最后一刻”让患者做出选择，将决策责任留给患者。在第三种模式中，他们早期就与患者、家属和医疗团队就不确定性和局限性进行共同思考和对话。这些模式趋势影响了患者对不确定性和局限性的态度，同时患者也受其影响。医生和患者都指出了共同探讨问题存在的个体和系统性障碍。
这项研究表明，在整个疾病过程中，这些艰难的决策在多大程度上与医生和患者各自以及相互影响的处理和分享不确定性和局限性的能力相关。这些见解可能有助于医生、患者和政策制定者加深对决策过程中被低估且敏感的关键问题的理解。
Little is known about what is at stake at a subjective level for the oncologists and the advanced cancer patients when they face the question whether to continue, limit or stop specific therapies. We studied (1) the frequency of such questioning, and (2) subjective determinants of the decision-making process from the physicians’ and the patients’ perspectives. (1) All hospitalized patients were screened during 1 week in oncology and/or hematology units of five institutions. We included those with advanced cancer for whom a questioning about the pursuit, the limitation or the withholding of specific therapies (QST) was raised. (2) Qualitative design was based on in-depth interviews. In conventional units, 12.8 % of cancer patients (26 out of 202) were concerned by a QST during the study period. Interviews were conducted with all physicians and 21 advanced cancer patients. The timing of this questioning occurred most frequently as physicians estimated life expectancy between 15 days and 3 months. Faced with the most frequent dilemma (uncertain risk-benefit balance), physicians showed different ways of involving patients. The first two were called the “no choice” models: 1) trying to resolve the dilemma via a technical answer or a “wait-and-see” posture, instead of involving the patients in the questioning and the thinking; and 2), giving a “last minute” choice to the patients, leaving to them the responsibility of the decision. In a third model, they engaged early in shared reflections and dialogue about uncertainties and limits with patients, proxies and care teams. These schematic trends influenced patients’ attitudes towards uncertainty and limits, as they were influenced by these ones. Individual and systemic barriers to a shared questioning were pointed out by physicians and patients. This study indicate to what extent these difficult decisions are related to physicians’ and patients’ respective and mutually influenced abilities to deal with and share about uncertainties and limits, throughout the disease trajectory. These insights may help physicians, patients and policy makers to enrich their understanding of underestimated and sensitive key issues of the decision-making process.