Barriers to Conducting Advance Care Discussions for Children With Life-Threatening Conditions
Barriers to Conducting Advance Care Discussions for Children With Life-Threatening Conditions
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DOI：
10.1542/peds.2011-2695
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发表时间：
2012-04-01
期刊：
影响因子：
8
通讯作者：
Wolfe, Joanne
中科院分区：
文献类型：
--
作者：
Durall, Amy;Zurakowski, David;Wolfe, Joanne
背景和目的：预先护理讨论（ACD）很少发生或在病程晚期才开始。尽管存在关于成人患者护理中 ACD 障碍的数据，但儿科数据却很少。本研究的目的是找出对患有危及生命的疾病的儿童进行 ACD 的障碍。方法：对通常进行预先护理计划的实践环境中的医生和护士进行调查，以收集有关他们对 ACD 的态度和行为的数据。结果：共有 266 名提供者对调查做出了回应：107 名医生和 159 名护士（回应率为 54%）。三大障碍是：家长的期望不切实际、临床医生和患者/家长对预后的理解存在差异，以及家长缺乏讨论的准备。与医生相比，护士更常认为临床医生缺乏重要性 (P = .006) 和道德考虑 (P < .001) 是障碍。相反，医生认为不知道该说什么（P = .006）更经常是一个障碍。专业之间也存在明显的差异。心脏 ICU 提供者更有可能报告不切实际的临床医生期望 (P < .001) 以及临床医生和患者/家长对预后的理解差异 (P = .014)，这是进行 ACD 的常见障碍。最后，71% 的临床医生认为 ACD 在患者的临床过程中发生得太晚。结论：临床医生认为父母对预后的理解和态度是进行 ACD 的最常见障碍。旨在提高临床医生解决这些障碍的知识、态度和技能的教育干预措施可能有助于医疗保健提供者克服感知到的障碍。儿科 2012；129：e975-e982
BACKGROUND AND OBJECTIVE: Advance care discussions (ACD) occur infrequently or are initiated late in the course of illness. Although data exist regarding barriers to ACD among the care of adult patients, few pediatric data exist. The goal of this study was to identify barriers to conducting ACD for children with life-threatening conditions.METHODS: Physicians and nurses from practice settings where advance care planning typically takes place were surveyed to collect data regarding their attitudes and behaviors regarding ACD.RESULTS: A total of 266 providers responded to the survey: 107 physicians and 159 nurses (54% response rate). The top 3 barriers were: unrealistic parent expectations, differences between clinician and patient/parent understanding of prognosis, and lack of parent readiness to have the discussion. Nurses identified lack of importance to clinicians (P = .006) and ethical considerations (P < .001) as impediments more often than physicians. Conversely, physicians believed that not knowing the right thing to say (P = .006) was more often a barrier. There are also perceived differences among specialties. Cardiac ICU providers were more likely to report unrealistic clinician expectations (P < .001) and differences between clinician and patient/parent understanding of prognosis (P = .014) as common barriers to conducting ACD. Finally, 71% of all clinicians believed that ACD happen too late in the patient's clinical course.CONCLUSIONS: Clinicians perceive parent prognostic understanding and attitudes as the most common barriers to conducting ACD. Educational interventions aimed at improving clinician knowledge, attitudes, and skills in addressing these barriers may help health care providers overcome perceived barriers. Pediatrics 2012;129:e975-e982