Bern-Klug Mercedes, Gessert Charles E, Crenner Christopher W, Buenaver Maritza, Skirchak Danielle
School of Social Work, The University of Iowa, Iowa City, Iowa 52242, USA.
J Palliat Med. 2004 Aug;7(4):533-44. doi: 10.1089/jpm.2004.7.533.
To improve understanding of nursing home physicians' perspectives regarding end-of-life care, and to suggest directions for further research.
An exploratory qualitative design based on interviews of 12 nursing home physicians, 10 of whom were medical directors. Medical students served as interviewers.
A purposeful sampling strategy yielded interviews with 12 physicians. The sample was selected based on "intensity sampling," which seeks information-rich but not extreme cases. Ten of the 12 physicians were nursing home medical directors; all respondents practiced at least 4 years part-time or full-time in a nursing home setting. Respondents varied by age, gender, urban/rural location, and fellowship training (half the sample had completed a geriatrics fellowship). Seven physicians were affiliated with an academic medical center.
Four themes were identified in the analysis of the 12 interview transcripts: extensive familiarity with dying; consensus is integral to good end-of-life care; obstacles can interfere with consensus; and advance directives set the stage for conversations about end-of-life care. The importance of consensus, both in terms of prognosis and in developing a palliative care plan, emerged as the major finding.
For the 12 physicians in this study consensus about the resident's status and an appropriate care plan are important features of good end-of-life care. Further research is needed to determine if other members of the health care team (i.e., residents, family members, nursing staff, social worker, etc.) also value consensus highly. It will be important to determine what barriers to consensus other team members identify. Based on the understanding generated from this study, a refinement of the general Education for Physicians on End-of-Life Care (EPEC) model describing the relationship between curative and palliative care is proposed for nursing homes. The refinement underscores the points at which the team might consider revisiting consensus about the resident's status and care plan.
增进对疗养院医生关于临终关怀观点的理解，并为进一步研究提出方向。
基于对12名疗养院医生的访谈进行探索性定性设计，其中10名是医疗主任。医学生担任访谈者。
采用有目的抽样策略对12名医生进行访谈。样本基于“强度抽样”选取，该方法旨在获取信息丰富但并非极端的案例。12名医生中有10名是疗养院医疗主任；所有受访者在疗养院环境中至少兼职或全职工作4年。受访者在年龄、性别、城乡地点和专科培训方面存在差异（样本中有一半完成了老年医学专科培训）。7名医生隶属于学术医疗中心。
对12份访谈记录的分析确定了四个主题：对死亡的广泛熟悉；共识是良好临终关怀不可或缺的；障碍可能干扰共识；预先指示为关于临终关怀的对话奠定基础。在预后和制定姑息治疗计划方面，共识的重要性成为主要发现。
对于本研究中的12名医生而言，就居民状况和适当的护理计划达成共识是良好临终关怀的重要特征。需要进一步研究以确定医疗团队的其他成员（即居民、家庭成员、护理人员、社会工作者等）是否也高度重视共识。确定其他团队成员所识别的共识障碍将很重要。基于本研究产生的理解，针对疗养院提出了对描述治愈性护理和姑息治疗之间关系的医生临终关怀通用教育（EPEC）模型的改进。该改进强调了团队可能考虑重新审视关于居民状况和护理计划的共识的关键点。
