1 Centre for Primary Health Care and Equity, University of New South Wales , Sydney, Australia .
J Palliat Med. 2013 Oct;16(10):1197-204. doi: 10.1089/jpm.2013.0156. Epub 2013 Aug 21.
Advance care planning (ACP) is thought to enhance patient autonomy and improve end-of-life care. However, there is evidence that when patients engage in ACP, the resultant plans are often not implemented. This has been attributed to either nonadherence by health professionals or inadequacies in ACP such as inaccessibility of the plans, plans providing ambiguous or conflicting instructions, and inappropriate focus on the completion of documents rather than communication. However, it is not known whether these postulated reasons are consistent with the experiences and views of health care professionals providing end-of-life care in the community.
Our aim was to explore the perspectives of general practitioners (GPs) on factors influencing the implementation of ACPs.
We conducted semi-structured, open-ended interviews of a purposive sample of 17 Australian GPs. Interview transcripts were analysed using constructionist grounded theory utilizing NVivo 9 software.
Factors that were considered to have an important influence on the implementation of ACPs include: ACP factors such as form, legal standing, accessibility, clarity, currency, and specificity; illness factors such as quality of life, function, diagnosis, prognosis, and prognostic certainty; family factors such as family attitudes to ACP and different conceptualizations on whether care is provided to individuals or to a family unit; and organizational and care setting factors such as health care facility's attitudes and policies in relation to end-of-life care.
Problems in implementation of ACPs are multifactorial and not necessarily due to deliberate nonadherence by health professionals. Potential solutions to improve the clinical impact of ACP are discussed.
预先医疗指示（ACP）被认为可以增强患者的自主权并改善临终关怀。然而，有证据表明，当患者参与 ACP 时，制定的计划往往无法实施。这归因于医疗保健专业人员的不遵守或 ACP 的不足，例如计划无法获取、计划提供的指令模糊或冲突以及对文件完成的关注而非沟通不充分。然而，尚不清楚这些假设的原因是否与在社区中提供临终关怀的医疗保健专业人员的经验和观点一致。
我们的目的是探讨全科医生（GP）对影响 ACP 实施的因素的看法。
我们对 17 名澳大利亚全科医生进行了有针对性的半结构式、开放式访谈。使用 NVivo 9 软件对访谈记录进行建构主义扎根理论分析。
被认为对 ACP 实施有重要影响的因素包括：ACP 因素，如形式、法律地位、可及性、清晰度、时效性和特异性；疾病因素，如生活质量、功能、诊断、预后和预后确定性；家庭因素，如家庭对 ACP 的态度以及对护理是提供给个人还是家庭单位的不同概念化；以及组织和护理环境因素，如医疗机构对临终关怀的态度和政策。
ACP 实施中的问题是多因素的，不一定是由于医疗保健专业人员故意不遵守。讨论了提高 ACP 临床效果的潜在解决方案。
