Workman S, Mann O E
Division of General Internal Medicine, QEII Health Science Centre, Halifax, Nova Scotia, Canada.
QJM. 2007 Jul;100(7):433-40. doi: 10.1093/qjmed/hcm042. Epub 2007 Jun 12.
In our institution, about one third of annual deaths occur on the general medical teaching unit. (MTU) The average patient dies on the MTU from non-malignant disease after 4 weeks in hospital, and approximately 20% of available beds on the MTU at any time are occupied by patients who will not survive to discharge, but quality of end-of-life care on the MTU is not routinely assessed.
To identify areas for improvement in delivering high quality end-of-life care on the medical teaching unit.
Qualitative study using semi-structured interviews.
Six months after the death of the patient, next of kin were sent a letter inviting participation; 75 family members were screened and 50 invitations were mailed out. Interviews were conducted in the home. Eliciting narratives and direct questioning about important aspects of end-of-life care were used.
Six next of kin agreed to participate. All patients were described as seriously and chronically ill. None died of cancer. Deaths were not described as 'good', and some comments suggested that death was unexpected and not inevitable. There were few concerns about pain control or unnecessary suffering. Proactive efforts to provide prognostic information or end-of-life care were not described. Survival, not palliation, was of central importance. Consistent with this priority, satisfaction with care provided in the intensive care unit was high. Follow-up after death was desired, especially if autopsy results were available.
Earlier discussions about treatment failure and end-of-life care, and the need for palliation, appear to be central to improving the quality of end-of-life care for patients dying on our medical teaching unit. Our results are consistent with other studies in this area.
在我们机构，每年约三分之一的死亡发生在普通内科教学病房（MTU）。MTU的患者平均在住院4周后因非恶性疾病死亡，且MTU随时约20%的可用床位被无法存活至出院的患者占用，但MTU的临终关怀质量未得到常规评估。
确定在医学教学病房提供高质量临终关怀方面需要改进的领域。
采用半结构式访谈的定性研究。
在患者死亡6个月后，向其近亲发送邀请信；筛选了75名家庭成员并寄出50份邀请信。访谈在患者家中进行。采用引出叙述和直接询问临终关怀重要方面的方法。
6名近亲同意参与。所有患者均被描述为患有严重慢性病。无一例死于癌症。死亡未被描述为“善终”，一些评论表明死亡出乎意料且并非不可避免。对疼痛控制或不必要的痛苦几乎没有担忧。未提及提供预后信息或临终关怀的积极努力。生存而非姑息治疗是核心关注点。与此优先事项一致，对重症监护病房提供的护理满意度较高。希望在患者死后进行随访，尤其是在有尸检结果的情况下。
更早地讨论治疗失败和临终关怀以及姑息治疗的必要性，似乎是提高我们医学教学病房临终患者临终关怀质量的核心。我们的结果与该领域的其他研究一致。
