Yale University School of Medicine, New Haven, CT, USA.
J Gen Intern Med. 2009 Aug;24(8):923-8. doi: 10.1007/s11606-009-1030-9. Epub 2009 Jun 9.
Clinicians' discussions about hospice with patients and families are important as a means of communicating end-of-life options.
To identify determinants of clinicians' hospice discussions and the impact of such discussions on hospice use.
We interviewed 215 patients age > or = 60 years with advanced cancer, chronic obstructive pulmonary disease (COPD), or heart failure (HF) at least every 4 months for up to 2 years. Participants provided information about their health status and treatment preferences. Clinicians completed a questionnaire every 6 months about their estimates of patient life expectancy and their communication with the patient and family about hospice.
In their final survey, clinicians reported discussing hospice with 46% of patients with cancer, compared to 10% with COPD and 7% with HF. Apart from diagnosis of cancer, the factors most strongly associated with hospice discussion were clinicians' estimate of and certainty about patient life expectancy (P < 0.001). However, clinicians were unable to anticipate the deaths of a considerable portion of patients (40%). Although patient unwillingness to undergo minor medical interventions was associated with hospice discussion (P < 0.05), a sizeable portion of clinicians (40%) whose patients reported this characteristic did not have the discussion. Clinicians' discussion of hospice independently increased the likelihood of hospice use (OR = 5.3, 95% CI = 2.3-13).
Clinicians' discussion of hospice for patients with advanced illness, and, ultimately, patients' use of hospice, relies largely on clinician estimates of patient life expectancy and the predictability of disease course. Many clinicians whose patients might benefit from learning about hospice are not having these discussions.
临床医生与患者和家属讨论临终关怀是很重要的，因为这是沟通临终选择的一种方式。
确定临床医生进行临终关怀讨论的决定因素，以及此类讨论对临终关怀使用的影响。
我们对 215 名年龄≥60 岁的晚期癌症、慢性阻塞性肺疾病（COPD）或心力衰竭（HF）患者进行了访谈，每 4 个月至少进行一次，持续 2 年。参与者提供了有关其健康状况和治疗偏好的信息。临床医生每 6 个月完成一次关于其对患者预期寿命的估计以及与患者和家属就临终关怀进行沟通的问卷。
在他们的最终调查中，临床医生报告说，在癌症患者中，有 46%的患者讨论了临终关怀，而 COPD 患者中有 10%，HF 患者中有 7%。除了癌症诊断外，与临终关怀讨论最密切相关的因素是临床医生对患者预期寿命的估计和确定性（P<0.001）。然而，相当一部分临床医生（40%）无法预测患者的死亡（40%）。尽管患者不愿意接受小的医疗干预与临终关怀讨论有关（P<0.05），但仍有相当一部分（40%）的患者报告有此特征的临床医生并未进行讨论。临床医生对临终关怀的讨论独立增加了临终关怀使用的可能性（OR=5.3，95%CI=2.3-13）。
临床医生对患有晚期疾病的患者进行临终关怀讨论，最终患者使用临终关怀，主要依赖于临床医生对患者预期寿命的估计和疾病过程的可预测性。许多可能从了解临终关怀中受益的患者的临床医生并没有进行这些讨论。
