Ruopp Patricia, Good Mary-Jo Delvecchio, Lakoma Matthew, Gadmer Nina M, Arnold Robert M, Block Susan D
Department of Social Medicine, Harvard Medical School, Boston, MA 02115, USA.
J Palliat Med. 2005 Jun;8(3):510-20. doi: 10.1089/jpm.2005.8.510.
The goal of the larger study was to explore physicians' emotional responses to the death of their patients; this study analyzed a subset of physician transcripts to elucidate the construct of questioning care, which emerged from the larger study.
To analyzes how physicians question care-expressing concern, unease, or uncertainty about treatment decisions and practices, errors, or adverse events-as they attend dying patients.
Retrospective interview study of physicians caring for randomly selected deaths on the medical service of a major academic teaching hospital, using qualitative and quantitative measures. SETTING, SUBJECTS: 188 attendings, residents, and interns on the internal medical services of two academic medical centers were part of the larger study. A subsample of 75 physician narratives was selected for qualitative data analysis for this study.
Qualitative measures included open-ended questions eliciting physicians' stories of the most recent and a most emotionally powerful patient death they have experienced. Grounded theory was used to analyze physician narratives. Quantitative instruments measured physician attitudes toward end-of-life care and responses to the most recent and most emotional patient death.
Physicians question care more frequently in most emotional deaths (42%) than in most recent deaths (34%). Physicians question communication with patients and families and within medical teams, medical judgment and technique, standards of practice, and high-risk treatments, often assigning responsibility for medical management they perceive as inappropriate, futile, overly aggressive, or mistakes in judgment and technique. Responsibility ranges from the distal (the culture of medicine) to the proximal (personal). Frustration, guilt, and anger are more frequently expressed in these narratives when care is questioned.
A typology of questioning care emerged from these physicians' narratives that parallels and reflects recent and classic research on medical error and the culture of medicine. Physicians' questions about care can contribute to designing training experiences for residents and to improving the quality of systems that affect patients' experiences at life's end and physicians' experiences in caring for dying patients.
规模更大的研究旨在探究医生对患者死亡的情绪反应；本研究分析了医生访谈记录的一个子集，以阐明从规模更大的研究中浮现出的对医疗护理提出质疑这一概念。
分析医生在照料临终患者时如何对医疗护理提出质疑——表达对治疗决策与实践、差错或不良事件的关切、不安或不确定。
采用定性和定量方法，对在一家大型学术教学医院内科病房随机挑选的死亡病例进行照料的医生开展回顾性访谈研究。
地点、研究对象：来自两家学术医疗中心内科病房的188名主治医生、住院医生和实习医生参与了规模更大的研究。本研究选取了75份医生叙述作为定性数据分析的子样本。
定性方法包括开放式问题，引出医生讲述他们经历的最近一例以及情感上最强烈的患者死亡事件。采用扎根理论分析医生的叙述。定量工具测量医生对临终护理的态度以及对最近和情感上最强烈的患者死亡事件的反应。
医生在情感上最强烈的死亡病例中（42%）比在最近的死亡病例中（34%）更频繁地对医疗护理提出质疑。医生质疑与患者及家属的沟通、医疗团队内部的沟通、医疗判断和技术、实践标准以及高风险治疗，常常将他们认为不恰当、无效、过度积极或判断及技术失误的医疗管理责任归咎于他人。责任范围从远端（医学文化）到近端（个人）。当医疗护理受到质疑时，这些叙述中更频繁地表达出沮丧、内疚和愤怒。
从这些医生的叙述中浮现出一种对医疗护理提出质疑的类型学，它与近期及经典的关于医疗差错和医学文化的研究相平行且反映了这些研究。医生对医疗护理的质疑有助于为住院医生设计培训体验，并改善影响患者临终体验及医生照料临终患者体验的系统质量。
