Knauft Elizabeth, Nielsen Elizabeth L, Engelberg Ruth A, Patrick Donald L, Curtis J Randall
Division of Pulmonary and Critical Care Medicine, Department of Medicine, School of Medicine, University of Washington, Seattle, USA.
Chest. 2005 Jun;127(6):2188-96. doi: 10.1378/chest.127.6.2188.
Patients with COPD frequently do not discuss end-of-life care with physicians; therefore, we sought to identify the barriers and facilitators to this communication as a first step to overcoming barriers and capitalizing on facilitators.
Fifteen barriers and 11 facilitators to patient-physician communication about end-of-life care were generated from focus groups of patients with COPD. We subsequently conducted a cross-sectional study of 115 patients with oxygen-dependent COPD and their physicians to identify the common barriers and facilitators and examine the association of these barriers and facilitators with communication about end-of-life care.
Patients with oxygen-dependent COPD were recruited from clinics at a university, county, and Veterans Affairs teaching hospital, and an oxygen delivery company. We also recruited the physician identified by each patient as the doctor primarily responsible for their lung disease.
Patients were interviewed by trained research interviewers. Physician data collection was completed by mail survey. Participation rates were 40% for patients and 86% for physicians. Only 32% of patients reported having a discussion about end-of-life care with their physician. Two of 15 barriers and 8 of 11 facilitators were endorsed by > 50% of patients. The most commonly endorsed barriers were "I'd rather concentrate on staying alive," and "I'm not sure which doctor will be taking care of me." Two barriers were significantly associated with lack of communication, as follows: "I don't know what kind of care I want," and "I'm not sure which doctor will be taking care of me." The greater the number of barriers endorsed by patients, the less likely they were to have discussed end-of-life care with physicians (p < 0.01), suggesting the validity of these barriers. Conversely, the more facilitators, the more likely patients were to report having had end-of-life discussions with their physicians (p < 0.001).
Although patients endorsed many barriers and facilitators, few barriers were endorsed by most patients. Barriers and facilitators associated with communication are targets for interventions to improve end-of-life care, but such interventions will likely need to address the specific barriers relevant to individual patient-physician pairs.
慢性阻塞性肺疾病（COPD）患者常常不与医生讨论临终关怀问题；因此，我们试图找出这种沟通的障碍和促进因素，作为克服障碍和利用促进因素的第一步。
通过对COPD患者焦点小组的讨论，得出了15个患者与医生关于临终关怀沟通的障碍和11个促进因素。随后，我们对115名依赖氧气的COPD患者及其医生进行了一项横断面研究，以确定常见的障碍和促进因素，并研究这些障碍和促进因素与临终关怀沟通之间的关联。
依赖氧气的COPD患者从一所大学、一个县和一家退伍军人事务教学医院的诊所以及一家氧气供应公司招募。我们还招募了每位患者指定的主要负责其肺部疾病的医生。
由经过培训的研究访谈员对患者进行访谈。医生的数据收集通过邮寄调查问卷完成。患者的参与率为40%，医生的参与率为86%。只有32%的患者报告与他们的医生讨论过临终关怀问题。15个障碍中的2个和11个促进因素中的8个得到了超过50%患者的认可。最常被认可的障碍是“我宁愿专注于活下去”和“我不确定哪个医生会照顾我”。有两个障碍与缺乏沟通显著相关，如下：“我不知道我想要哪种护理”和“我不确定哪个医生会照顾我”。患者认可的障碍数量越多，他们与医生讨论临终关怀的可能性就越小（p < 0.01），这表明这些障碍的有效性。相反，促进因素越多，患者报告与医生进行过临终讨论的可能性就越大（p < 0.001）。
尽管患者认可了许多障碍和促进因素，但大多数患者认可的障碍很少。与沟通相关的障碍和促进因素是改善临终关怀干预措施的目标，但此类干预措施可能需要解决与个体患者 - 医生对相关的特定障碍。
