Curtis J R, Patrick D L, Caldwell E S, Collier A C
Department of Medicine, University of Washington, Seattle 98104-2499, USA.
Arch Intern Med. 2000 Jun 12;160(11):1690-6. doi: 10.1001/archinte.160.11.1690.
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.
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.
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.
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."
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.
患有慢性和终末期疾病的患者常常不与医生谈论临终关怀问题。旨在改善这种沟通的干预措施通常并不成功，这表明这种沟通必定存在重要障碍。
确定患者与临床医生就临终关怀进行沟通的障碍和促进因素，并找出在最不可能讨论临终关怀的患者（少数族裔和注射吸毒者）中更常见的障碍和促进因素。
我们对57名晚期获得性免疫缺陷综合征患者及其从大学诊所和私人诊所招募的初级保健临床医生进行了一项前瞻性研究。根据先前的定性研究确定了临终沟通的障碍和促进因素，并对其频率、重要性以及与临终沟通的发生和质量的关联进行了评估。
临床医生识别出的障碍比患者更多。患者和临床医生识别出的障碍可分为三类潜在干预措施：临终关怀教育、帮助解决临终担忧的咨询以及促进患者与临床医生沟通的医疗保健系统变革。虽然患者识别出的障碍均与沟通的发生无关，但临床医生识别出的两个障碍与沟通较少有关：“患者尚未病得很重”和“患者尚未准备好谈论临终关怀”。与白人患者相比，非白人患者更有可能识别出以下两个障碍：“我觉得如果谈论死亡，可能会让死亡来得更近”和“如果病得很重，我不喜欢谈论我想要的护理”。
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具有多样性，这表明改善临终关怀沟通的干预措施必须针对个体需求，除教育外还必须包括咨询干预和医疗系统变革。临床医生的障碍比患者的障碍更常见，且与临终沟通的发生关联更强，这表明临床医生是改善这种沟通的重要目标群体。
