Homing in on the Social: System-Level Influences on Overly Aggressive Treatments at the End of Life
Homing in on the Social: System-Level Influences on Overly Aggressive Treatments at the End of Life
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DOI：
10.1016/j.jpainsymman.2017.08.019
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发表时间：
2018-02-01
影响因子：
4.7
通讯作者：
Ritchie, Christine S.
中科院分区：
文献类型：
--
作者：
Dzeng, Elizabeth;Dohan, Daniel;Ritchie, Christine S.
上下文美国医疗系统被编程为对绝症患者进行积极护理的默认设置。决策制定的制度规范已被证明可以促进高强度护理，无论与患者的偏好是否一致。在系统、临床医生、代理人和患者层面上，有无数因素推动了美国医院过度积极治疗的文化。本研究的目的是了解医生的角度的方式系统水平的因素影响病人，医生和代理人的看法和随之而来的行为。半结构化的深入定性访谈42名内科医生在三个美国学术医疗中心进行。这项定性研究的性质是探索性的，旨在提高概念的理解，驱动医生的态度和行为的基本现象。访谈揭示了许多导致生命结束时过度积极治疗的因素。系统性因素描述了潜在的文化（包括机构、专业或社区文化）、典型的护理实践或驱动护理模式的系统性默认，直接或通过其对患者、代理人和医生行为和态度的影响表现出其影响。机构文化，社会规范和系统默认影响规范信念的护理标准和治疗计划，可能不会使重病患者受益。(C)2017年美国临终关怀和姑息医学学会。爱思唯尔公司出版All rights reserved.
Context. The American Medical System is programmed to a default setting of aggressive care for the terminally ill. Institutional norms of decision making have been shown to promote high-intensity care, regardless of consistency with patient preferences. There are myriad factors at a system, clinician, surrogate, and patient level that drive the culture of overly aggressive treatments in American hospitals.Objective. The objective of this study was to understand physician perspective of the ways systems-level factors influence patient, physician, and surrogate perceptions and consequent behavior.Methods. Semi-structured in-depth qualitative interviews with 42 internal medicine physicians across three American academic medical centers were conducted. This qualitative study was exploratory in nature, intended to enhance conceptual understanding of underlying phenomena that drive physician attitudes and behavior.Results. The interviews revealed many factors that contributed to overly aggressive treatments at the end of life. Systemic factors, which describe underlying cultures (including institutional, professional, or community-based cultures), typical practices of care, or systemic defaults that drive patterns of care, manifested its influence both directly and through its impact on patient, surrogate, and physician behaviors and attitudes.Conclusion. Institutional cultures, social norms, and systemic defaults influence both normative beliefs regarding standards of care and treatments plans that may not benefit seriously ill patients. (C) 2017 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.