“人们所期待的并非那逐渐熄灭的蜡烛”：全科医生对临终家庭护理中维持生命与“放手”决策的看法。
"It is not the fading candle that one expects": general practitioners' perspectives on life-preserving versus "letting go" decision-making in end-of-life home care.
作者信息
Sercu Maria, Renterghem Veerle Van, Pype Peter, Aelbrecht Karolien, Derese Anselme, Deveugele Myriam
机构信息
a Department of Family Medicine and Primary Health Care , Ghent University , Belgium ;
b Veerle Van Renterghem , Kalestraat 25 , 9940 Evergem , Belgium.
出版信息
Scand J Prim Health Care. 2015;33(4):233-42. doi: 10.3109/02813432.2015.1118837. Epub 2015 Dec 10.
BACKGROUND
Many general practitioners (GPs) are willing to provide end-of-life (EoL) home care for their patients. International research on GPs' approach to care in patients' final weeks of life showed a combination of palliative measures with life-preserving actions.
AIM
To explore the GP's perspective on life-preserving versus "letting go" decision-making in EoL home care.
DESIGN
Qualitative analysis of semi-structured interviews with 52 Belgian GPs involved in EoL home care.
RESULTS
Nearly all GPs adopted a palliative approach and an accepting attitude towards death. The erratic course of terminal illness can challenge this approach. Disruptive medical events threaten the prospect of a peaceful end-phase and death at home and force the GP either to maintain the patient's (quality of) life for the time being or to recognize the event as a step to life closure and "letting the patient go". Making the "right" decision was very difficult. Influencing factors included: the nature and time of the crisis, a patient's clinical condition at the event itself, a GP's level of determination in deciding and negotiating "letting go" and the patient's/family's wishes and preparedness regarding this death. Hospitalization was often a way out.
CONCLUSIONS
GPs regard alternation between palliation and life-preservation as part of palliative care. They feel uncertain about their mandate in deciding and negotiating the final step to life closure. A shortage of knowledge of (acute) palliative medicine as one cause of difficulties in letting-go decisions may be underestimated. Sharing all these professional responsibilities with the specialist palliative home care teams would lighten a GP's burden considerably. Key Points A late transition from a life-preserving mindset to one of "letting go" has been reported as a reason why physicians resort to life-preserving actions in an end-of-life (EoL) context. We investigated GPs' perspectives on this matter. Not all GPs involved in EoL home care adopt a "letting go" mindset. For those who do, this mindset is challenged by the erratic course of terminal illness. GPs prioritize the quality of the remaining life and the serenity of the dying process, which is threatened by disruptive medical events. Making the "right" decision is difficult. GPs feel uncertain about their own role and responsibility in deciding and negotiating the final step to life closure.
背景
许多全科医生（GP）愿意为其患者提供临终家庭护理。关于全科医生在患者生命最后几周的护理方法的国际研究表明，姑息措施与维持生命的行动相结合。
目的
探讨全科医生在临终家庭护理中对维持生命与“放手”决策的看法。
设计
对52名参与临终家庭护理的比利时全科医生进行半结构化访谈的定性分析。
结果
几乎所有的全科医生都采取了姑息治疗方法并对死亡持接受态度。晚期疾病的不稳定病程可能会对这种方法构成挑战。破坏性的医疗事件威胁着在家中平静度过终末期和死亡的前景，迫使全科医生要么暂时维持患者的生活（质量），要么将该事件视为迈向生命终结和“让患者离去”的一步。做出“正确”的决定非常困难。影响因素包括：危机的性质和时间、事件发生时患者的临床状况、全科医生在决定和协商“放手”时的决心程度以及患者/家属对这种死亡的意愿和准备情况。住院治疗往往是一种解决办法。
结论
全科医生将姑息治疗与维持生命之间的交替视为姑息治疗的一部分。他们对自己在决定和协商生命终结的最后一步中的职责感到不确定。作为难以做出“放手”决定的一个原因，对（急性）姑息医学知识的缺乏可能被低估了。与专科姑息家庭护理团队分担所有这些专业职责将大大减轻全科医生的负担。要点 据报道，从维持生命的心态到“放手”心态的转变过晚是医生在临终（EoL）情况下采取维持生命行动的一个原因。我们调查了全科医生对此事的看法。并非所有参与临终家庭护理的全科医生都采取“放手”心态。对于那些采取这种心态的人来说，这种心态受到晚期疾病不稳定病程的挑战。全科医生将剩余生命的质量和临终过程的平静视为优先事项，而这受到破坏性医疗事件的威胁。做出“正确”的决定很困难。全科医生对自己在决定和协商生命终结的最后一步中的角色和责任感到不确定。
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