Barriers to Goals of Care Discussions With Seriously Ill Hospitalized Patients and Their Families A Multicenter Survey of Clinicians
Barriers to Goals of Care Discussions With Seriously Ill Hospitalized Patients and Their Families A Multicenter Survey of Clinicians
复制标题
DOI：
10.1001/jamainternmed.2014.7732
复制
发表时间：
2015-04-01
影响因子：
39
通讯作者：
Heyland, Daren K.
中科院分区：
文献类型：
--
作者：
You, John J.;Downar, James;Heyland, Daren K.
重要性重病住院患者已将有关护理目标的沟通和决策确定为提高临终护理质量的高度优先事项。目的从医院临床医生的角度出发，确定（1）阻碍与重症住院患者及其家属沟通和决策的障碍，以及（2）他们自己的意愿和其他临床医生参与这一过程的可接受性。和参与者多中心调查的医疗教学单位的护士，内科住院医师，和工作人员的医生从参与单位在13所大学为基础的医院从5个加拿大provinces.Main结果和措施的重要性，21个障碍的目标，护理讨论评为7点量表（1）极不重要;结果：2012年9月至2013年3月，1617名合格的临床医生中有1256名返回了问卷，总体应答率为77.7%。（646名护士中有512名[79.3%]，634名住院医师中有484名[76.3%]，337名医生中有260名[77.2%]）。以下家庭成员相关和患者相关因素被所有3个临床医生组一致确定为实现护理讨论目标的最重要障碍：家属或患者难以接受不良预后（平均[SD]评分分别为5.8 [1.2]和5.6 [1.3]），家属或患者难以理解维持生命治疗的局限性和并发症（两组均为5.8 [1.2]），家庭成员对护理目标的分歧（5.8 [1.2]），以及患者无法做出护理决策的目标（5.6 [1.2]）。临床医生认为他们自己的技能和系统因素是不太重要的障碍。参与者认为这是可以接受的所有临床医生群体参与护理讨论的目标，包括提前实践护士，护士和社会工作者的角色，发起护理讨论的目标，并成为一个决策coacher.CONCLUSIONS和相关性医院为基础的临床医生认为家庭成员相关和患者相关的因素作为最重要的障碍护理讨论的目标。所有的卫生保健专业人员被视为在解决护理目标发挥重要作用。这些发现可以为未来干预措施的设计提供信息，以改善有关护理目标的沟通和决策。
IMPORTANCE Seriously ill hospitalized patients have identified communication and decision making about goals of care as high priorities for quality improvement in end-of-life care. Interventions to improve care are more likely to succeed if tailored to existing barriers.OBJECTIVE To determine, from the perspective of hospital-based clinicians, (1) barriers impeding communication and decision making about goals of care with seriously ill hospitalized patients and their families and (2) their own willingness and the acceptability for other clinicians to engage in this process.DESIGN, SETTING, AND PARTICIPANTS Multicenter survey of medical teaching units of nurses, internal medicine residents, and staff physicians from participating units at 13 university-based hospitals from 5 Canadian provinces.MAIN OUTCOMES AND MEASURES Importance of 21 barriers to goals of care discussions rated on a 7-point scale (1 = extremely unimportant; 7 = extremely important).RESULTS Between September 2012 and March 2013, questionnaires were returned by 1256 of 1617 eligible clinicians, for an overall response rate of 77.7%(512 of 646 nurses [79.3%], 484 of 634 residents [76.3%], 260 of 337 staff physicians [77.2%]). The following family member-related and patient-related factors were consistently identified by all 3 clinician groups as the most important barriers to goals of care discussions: family members' or patients' difficulty accepting a poor prognosis (mean [SD] score, 5.8 [1.2] and 5.6 [1.3], respectively), family members' or patients' difficulty understanding the limitations and complications of life-sustaining treatments (5.8 [1.2] for both groups), disagreement among family members about goals of care (5.8 [1.2]), and patients' incapacity to make goals of care decisions (5.6 [1.2]). Clinicians perceived their own skills and system factors as less important barriers. Participants viewed it as acceptable for all clinician groups to engage in goals of care discussions-including a role for advance practice nurses, nurses, and social workers to initiate goals of care discussions and be a decision coach.CONCLUSIONS AND RELEVANCE Hospital-based clinicians perceive family member-related and patient-related factors as the most important barriers to goals of care discussions. All health care professionals were viewed as playing important roles in addressing goals of care. These findings can inform the design of future interventions to improve communication and decision making about goals of care.