Tulsky James A
Center for Palliative Care and the Department of Medicine, Duke University, and the Veterans Affairs Medical Center, Durham, North Carolina 27705, USA.
J Palliat Med. 2005;8 Suppl 1:S95-102. doi: 10.1089/jpm.2005.8.s-95.
Whether patient suffering is caused by physical symptoms, unwanted medical intervention, or spiritual crisis, the common pathway to relief is through a provider who is able to elicit these concerns and is equipped to help the patient and family address them. This paper reviews the current state of knowledge in communication at the end of life, organized according to a framework of information gathering, information giving, and relationship building; and then focuses on interventions to enhance communication among patients, providers, and families. Several observations emerge from the existing literature. Patients have highly individualized desires for information and we cannot predict patient preferences. Communication coding methodology has advanced significantly yet the current systems remain poorly understood and largely inaccessible. Physicians and other health care providers do not discuss sufficiently treatment options, quality of life or respond to emotional cues from patients, and there is plenty of room for improvement. On the positive side, we have also learned that physicians and other health care providers can be taught to communicate better through intensive communication courses, and that communication interventions can improve some patient outcomes. Finally, huge gaps remain in our current knowledge, particularly with regard to understanding the relationship between communication style and outcomes. These findings suggest several recommendations. We should create larger and more diverse datasets; improve upon the analysis of recorded communication data; increase our knowledge about patient preferences for information; establish a stronger link between specific communication behaviors and outcomes; and identify more efficient ways to teach providers communication skills.
无论患者的痛苦是由身体症状、不必要的医疗干预还是精神危机引起的，缓解痛苦的共同途径是通过能够引发这些担忧并具备帮助患者及其家人解决这些问题能力的医疗服务提供者。本文根据信息收集、信息提供和关系建立的框架，回顾了临终沟通的当前知识状态；然后重点关注增强患者、医疗服务提供者和家属之间沟通的干预措施。现有文献中有几点观察结果。患者对信息有高度个性化的需求，我们无法预测患者的偏好。沟通编码方法有了显著进步，但目前的系统仍未得到充分理解且大多难以获取。医生和其他医疗服务提供者没有充分讨论治疗选择、生活质量或回应患者的情感线索，仍有很大的改进空间。从积极的方面来看，我们也了解到通过强化沟通课程可以教会医生和其他医疗服务提供者更好地沟通，并且沟通干预可以改善一些患者的结局。最后，我们目前的知识仍存在巨大差距，尤其是在理解沟通方式与结局之间的关系方面。这些发现提出了几点建议。我们应该创建更大、更多样化的数据集；改进对记录的沟通数据的分析；增加我们对患者信息偏好的了解；在特定沟通行为与结局之间建立更紧密的联系；并确定更有效的方法来教授医疗服务提供者沟通技巧。
