Department of Family Medicine, 205 College Plaza, University of Alberta, 8215-112 Street, Edmonton, Alberta, T6G 2C8, Canada.
BMC Fam Pract. 2013 Jan 22;14:14. doi: 10.1186/1471-2296-14-14.
Substitute decision-makers are integral to the care of dying patients and make many healthcare decisions for patients. Unfortunately, conflict between physicians and surrogate decision-makers is not uncommon in end-of-life care and this could contribute to a "bad death" experience for the patient and family. We aim to describe Canadian family physicians' experiences of conflict with substitute decision-makers of dying patients to identify factors that may facilitate or hinder the end-of-life decision-making process. This insight will help determine how to best manage these complex situations, ultimately improving the overall care of dying patients.
Grounded Theory methodology was used with semi-structured interviews of family physicians in Edmonton, Canada, who experienced conflict with substitute decision-makers of dying patients. Purposeful sampling included maximum variation and theoretical sampling strategies. Interviews were audio-taped, and transcribed verbatim. Transcripts, field notes and memos were coded using the constant-comparative method to identify key concepts until saturation was achieved and a theoretical framework emerged.
Eleven family physicians with a range of 3 to 40 years in clinical practice participated.The family physicians expressed a desire to achieve a "good death" and described their role in positively influencing the experience of death.Finding Common Ground to Achieve a "Good Death" for the Patient emerged as an important process which includes 1) Building Mutual Trust and Rapport through identifying key players and delivering manageable amounts of information, 2) Understanding One Another through active listening and ultimately, and 3) Making Informed, Shared Decisions. Facilitators and barriers to achieving Common Ground were identified. Barriers were linked to conflict. The inability to resolve an overt conflict may lead to an impasse at any point. A process for Resolving an Impasse is described.
A novel framework for developing Common Ground to manage conflicts during end-of-life decision-making discussions may assist in achieving a "good death". These results could aid in educating physicians, learners, and the public on how to achieve productive collaborative relationships during end-of-life decision-making for dying patients, and ultimately improve their deaths.
在临终关怀中，替代决策人是患者护理的重要组成部分，他们为患者做出许多医疗决策。不幸的是，在临终关怀中，医生和替代决策人之间的冲突并不罕见，这可能导致患者和家属经历“糟糕的死亡”。我们旨在描述加拿大家庭医生与临终患者替代决策人冲突的经验，以确定可能促进或阻碍临终决策过程的因素。这种洞察力将有助于确定如何最好地管理这些复杂情况，最终改善临终患者的整体护理。
采用扎根理论方法，对加拿大埃德蒙顿的家庭医生进行半结构化访谈，这些医生在与临终患者的替代决策人发生冲突时经历了这种情况。目的抽样包括最大变异和理论抽样策略。访谈进行了录音，并逐字转录。使用恒比比较法对转录本、现场笔记和备忘录进行编码，以识别关键概念，直到达到饱和并出现理论框架为止。
11 名家庭医生参与了这项研究，他们的临床实践经验从 3 年到 40 年不等。家庭医生表达了对实现“善终”的渴望，并描述了他们在积极影响死亡体验方面的作用。“为患者实现‘善终’寻找共同基础”被视为一个重要的过程，包括 1）通过识别关键角色和提供可管理的信息量来建立相互信任和融洽关系，2）通过积极倾听来相互理解，最终 3）做出明智的、共同的决策。确定了达成共同基础的促进因素和障碍。障碍与冲突有关。无法解决明显的冲突可能会导致在任何时候陷入僵局。描述了一种解决僵局的过程。
一种用于在临终决策讨论中建立共同基础以管理冲突的新框架，可能有助于实现“善终”。这些结果可能有助于教育医生、学习者和公众如何在临终患者的临终决策中建立富有成效的合作关系，并最终改善他们的死亡。
