Furman Christian Davis, Kelly Susan E, Knapp Keith, Mowery Robyn L, Miles Toni
Department of Family and Geriatric Medicine, University of Louisville, Louisville, KY 40202, USA.
J Am Med Dir Assoc. 2007 Mar;8(3 Suppl 2):e35-41. doi: 10.1016/j.jamda.2006.12.006.
To identify enablers and barriers facing providers and staff in initiating Goals of Care (GOC) discussions with patients in the nursing home.
Qualitative methods, one-on-one interviews. The interviews began with eliciting the participant's definition of GOC. The open-ended questions were designed to assess recent experience and satisfaction with the participant's role in the GOC discussion.
Nursing home.
We interviewed 23 nursing home staff and providers.
Transcripts were qualitatively analyzed.
Five themes emerged that were identified as barriers to discussing GOC: (1) Fear of legal ramifications; (2) Not enough education on how to have a GOC discussion; (3) Family not involved on a regular basis; (4) Time pressure; (5) Interdisciplinary team not involved. Five themes also emerged that were identified as enablers to the GOC discussion: (1) Education/experience with the GOC discussion; (2) Interdisciplinary team involved in the discussion; (3) Established trusting relationship with the patient/family/other staff; (4) Terminal diagnosis/hospice involvement; (5) Discussion occurs in-person.
A major finding of these interviews is the lack of systematic attention to GOC in the nursing home setting. Since education and experience were identified as crucial to understanding GOC, more formal education and observed practice discussing GOC is needed for all staff. The outcomes of GOC discussions should be documented in the patient record and be accessible to all staff and communicated systematically to all staff. Addressing these barriers and facilitating these enablers to the GOC discussion will improve the care of nursing home patients.
确定疗养院医护人员与患者展开照护目标（GOC）讨论时面临的促进因素和障碍。
定性研究方法，一对一访谈。访谈首先引出参与者对GOC的定义。开放式问题旨在评估参与者近期在GOC讨论中的经历及对自身角色的满意度。
疗养院。
我们访谈了23名疗养院工作人员和医护人员。
对访谈记录进行定性分析。
出现了五个被确定为GOC讨论障碍的主题：（1）担心法律后果；（2）对如何进行GOC讨论的教育不足；（3）家属未定期参与；（4）时间压力；（5）跨学科团队未参与。还出现了五个被确定为GOC讨论促进因素的主题：（1）对GOC讨论的教育/经验；（2）跨学科团队参与讨论；（3）与患者/家属/其他工作人员建立了信任关系；（4）终末期诊断/临终关怀参与；（5）面对面讨论。
这些访谈的一个主要发现是疗养院环境中对GOC缺乏系统性关注。由于教育和经验被认为对理解GOC至关重要，因此所有工作人员都需要更正规的教育以及观察GOC讨论的实践。GOC讨论的结果应记录在患者病历中，供所有工作人员查阅，并系统地传达给所有工作人员。克服这些障碍并促进这些GOC讨论的促成因素将改善疗养院患者的护理。
