Schonfeld Toby L, Stevens Elizabeth A, Lampman Michelle A, Lyons William L
Bioethics Program, Center for Ethics, Emory University, 1531 Dickey Drive, Atlanta, GA 30322, USA.
Am J Hosp Palliat Care. 2012 Jun;29(4):260-7. doi: 10.1177/1049909111418778. Epub 2011 Aug 25.
This study reports on physicians' experiences in conducting end-of-life conversations with elderly patients who suffered from multiple co-morbidities (MCM). Our hypothesis was that both the lack of prognostic certainty and the lack of good communication tools contributed to physicians' discomfort with conducting EOL conversations with patients and families of patients with these conditions especially when compared with patients and families of patients who had a single, clear terminal diagnosis (e.g. pancreatic cancer).
Focus group questions were semi-structured and explored three general themes: (1) differences between having an end-of-life conversation with patients/families with MCM versus those with a single, terminal diagnosis; (2) timing of the end-of-life conversation; and (3) approaches to the end-of-life conversation.
Three themes emerged: (1) It is more difficult for them to have EOL conversations with patients with MCM and their families, as opposed to conversations with families and patients who have a clear, terminal diagnosis. (2) In deciding when to raise the subject of EOL care, participants reported that they rely on a number of physical and/or social signs to prompt these discussions. Yet a major reason for the difficulty that providers face in initiating these discussions with MCM patients and families is that there is a lack of a clear threshold or prompting event. (3) Participants mentioned three types of approaches to initiating EOL conversations: (a) direct approach, (b) indirect approach, (c) collaborative approach.
Prognostic indicies and communication scripts may better prepare physicians to facilitate end-of-life conversations with MCM patients/families.
本研究报告了医生与患有多种合并症（MCM）的老年患者进行临终谈话的经历。我们的假设是，缺乏预后确定性和良好的沟通工具导致医生在与这些疾病患者及其家属进行临终谈话时感到不适，尤其是与那些患有单一明确终末期诊断（如胰腺癌）的患者及其家属相比。
焦点小组问题采用半结构化形式，探讨了三个总体主题：（1）与患有MCM的患者/家属进行临终谈话与与患有单一终末期诊断的患者/家属进行临终谈话之间的差异；（2）临终谈话的时机；（3）临终谈话的方法。
出现了三个主题：（1）与患有MCM的患者及其家属进行临终谈话比与患有明确终末期诊断的患者及其家属进行谈话更困难。（2）在决定何时提出临终关怀主题时，参与者报告说他们依靠一些身体和/或社会迹象来促使进行这些讨论。然而，提供者在与MCM患者及其家属开始这些讨论时面临困难的一个主要原因是缺乏明确的阈值或提示事件。（3）参与者提到了三种启动临终谈话的方法：（a）直接方法，（b）间接方法，（c）协作方法。
预后指标和沟通脚本可能会让医生更好地为与MCM患者/家属进行临终谈话做好准备。
