Mack Jennifer W, Block Susan D, Nilsson Matthew, Wright Alexi, Trice Elizabeth, Friedlander Robert, Paulk Elizabeth, Prigerson Holly G
Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, MA, USA.
Cancer. 2009 Jul 15;115(14):3302-11. doi: 10.1002/cncr.24360.
Patients consider their human connection with a physician an important aspect of end-of-life (EOL) care. In this study, the authors sought to develop and validate a measure of therapeutic alliance between patients with advanced cancer and their physicians and to evaluate the effects of therapeutic alliance on EOL experiences and care.
The Human Connection (THC) scale was developed to measure the extent to which patients felt a sense of mutual understanding, caring, and trust with their physicians. The scale was administered to 217 patients with advanced cancer along with measures of attributes that have been related hypothetically to therapeutic alliance, including emotional acceptance of terminal illness. EOL outcomes in 90 patients who died during the study also were examined.
The 16-item THC questionnaire was consistent internally (Cronbach alpha = .90) and valid based on its expected positive association with emotional acceptance of terminal illness (r = .31; P < .0001). THC scores were related inversely to symptom burden (r = -.19; P = .006), functional status (Karnofsky performance status; r = .22; P = .001), and mental illness (THC score: 50.69 for patients with any Diagnostic and Statistical Manual [DSM] diagnosis vs 55.22 for patients with no DSM diagnosis; P = .03). THC scores were not associated significantly with EOL discussions (P = .68). Among the patients who died, EOL intensive care unit (ICU) care was associated inversely with therapeutic alliance (THC score: 46.5 for patients who received ICU care vs 55.5 for patients without ICU care; P = .002), so that patients with higher THC scores were less likely to spend time in the ICU during the last week of life.
The THC scale is a valid and reliable measure of therapeutic alliance between patients with advanced cancer and their physicians. In addition, there was no evidence to suggest that EOL discussions harm patients' therapeutic alliance. A strong therapeutic alliance was associated with emotional acceptance of a terminal illness and with decreased ICU care at the EOL among patients with advanced cancer.
患者认为他们与医生之间的人际联系是临终关怀的一个重要方面。在本研究中，作者试图开发并验证一种衡量晚期癌症患者与其医生之间治疗联盟的方法，并评估治疗联盟对临终体验和护理的影响。
开发了人际联系（THC）量表，以衡量患者对与医生之间相互理解、关怀和信任的感受程度。该量表应用于217名晚期癌症患者，并同时测量了假设与治疗联盟相关的属性，包括对绝症的情感接受度。还对研究期间死亡的90名患者的临终结局进行了检查。
16项THC问卷在内部是一致的（克朗巴赫α系数 = 0.90），并且基于其与对绝症的情感接受度的预期正相关而有效（r = 0.31；P < 0.0001）。THC得分与症状负担呈负相关（r = -0.19；P = 0.006），与功能状态（卡诺夫斯基功能状态评分；r = 0.22；P = 0.001）以及精神疾病呈负相关（THC得分：有任何《精神疾病诊断与统计手册》（DSM）诊断的患者为50.69，无DSM诊断的患者为55.22；P = 0.03）。THC得分与临终讨论无显著关联（P = 0.68）。在死亡的患者中，临终重症监护病房（ICU）护理与治疗联盟呈负相关（THC得分：接受ICU护理的患者为46.5，未接受ICU护理的患者为55.5；P = 0.002），因此THC得分较高的患者在生命最后一周在ICU度过的时间较少。
THC量表是衡量晚期癌症患者与其医生之间治疗联盟的有效且可靠的方法。此外，没有证据表明临终讨论会损害患者的治疗联盟。强大的治疗联盟与对绝症的情感接受度以及晚期癌症患者临终时减少的ICU护理相关。
