Wotton Karen, Borbasi Sally, Redden Maurine
School of Nursing & Midwifery, Flinders University, Adelaide, South Australia.
J Cardiovasc Nurs. 2005 Jan-Feb;20(1):18-25. doi: 10.1097/00005082-200501000-00006.
The purpose of this study was to describe registered nurses' (RNs') perceptions of factors influencing care for patients in the palliative phase of end-stage heart failure (ESHF). Seventeen senior RNs across 3 acute care and 5 community centres in metropolitan Adelaide, Australia, participated in the study. In this descriptive, exploratory research project, we analyzed audiotaped indepth, semistructured interviews, using a computer-assisted (NVIVO) thematic procedure. According to participants, the care of patients with ESHF is dominated by a focus on symptom management and optimal pharmacologic therapies, with a perceived deficit in other aspects of palliative management. Key mitigating factors against quality palliative care for this population included the difficulty in recognising ESHF and reluctance by physicians to negotiate end-of-life decisions. In the acute care sector, nurses believed ESHF was medicalized and characterized by paternalistic care, with treatment generally curative to the last breath. Nursing care and patient advocacy were also negatively influenced by a lack of awareness in patients and families concerning the inevitability of death in ESHF until the last few days or hours before death. Involvement of the palliative care team was often an afterthought rather than an integral component of care. Nurses in acute care settings embraced the concept of a multidisciplinary team approach, but stressed the need for the cardiac team to be the overall coordinator of care for the ESHF population. Care of patients with ESHF should promote the amalgamation of technological and pharmaceutical advances in the treatment of heart failure with more timely end-of-life care. All involved parties must work toward advancing a common middle ground for appropriate end-of-life care for patients with ESHF. Recommendations for practice include the need for greater education for patients and their families and greater collaboration between the members of the multidisciplinary healthcare team to assist patients with ESHF and their families prepare more timely for the final trajectory of the illness.
本研究的目的是描述注册护士对影响终末期心力衰竭（ESHF）姑息治疗阶段患者护理因素的看法。澳大利亚阿德莱德市3家急性护理中心和5家社区中心的17名资深注册护士参与了该研究。在这个描述性的探索性研究项目中，我们使用计算机辅助（NVIVO）主题程序分析了录音的深度、半结构化访谈。根据参与者的说法，ESHF患者的护理主要集中在症状管理和最佳药物治疗上，而在姑息治疗的其他方面则存在明显不足。针对这一人群提供高质量姑息治疗的关键缓解因素包括难以识别ESHF以及医生不愿协商临终决定。在急性护理部门，护士们认为ESHF被医学化，其特点是家长式护理，治疗通常直到最后一口气都是治愈性的。患者和家属直到死亡前几天或几小时才意识到ESHF中死亡的不可避免性，这也对护理和患者权益倡导产生了负面影响。姑息治疗团队的参与往往是事后才想到的，而不是护理的一个组成部分。急性护理环境中的护士接受多学科团队方法的概念，但强调心脏团队需要成为ESHF人群护理的总体协调者。ESHF患者的护理应促进心力衰竭治疗中技术和药物进展与更及时的临终护理的融合。所有相关方必须努力为ESHF患者推进适当的临终护理的共同中间立场。实践建议包括需要对患者及其家属进行更多教育，以及多学科医疗团队成员之间加强合作，以帮助ESHF患者及其家属更及时地为疾病的最终进程做好准备。
