Gigon Fabienne, Merlani Paolo, Ricou Bara
From the Intensive Care Unit, Department of Anesthesiology, Pharmacology and Intensive Care, Geneva University Hospitals and University of Geneva, Geneva, Switzerland (FG, BR) and Intensive Care Medicine, Ospedale Regionale di Lugano, Lugano, Switzerland (PM).
Medicine (Baltimore). 2015 Dec;94(49):e2112. doi: 10.1097/MD.0000000000002112.
Advance directives (AD) were developed to respect patient autonomy. However, very few patients have AD, even in cases when major cardiovascular surgery is to follow. To understand the reasons behind the low prevalence of AD and to help decision making when patients are incompetent, it is necessary to focus on the impact of prehospital practitioners, who may contribute to an increase in AD by discussing them with patients. The purpose of this study was to investigate self-rated communication skills and the attitudes of physicians potentially involved in the care of cardiovascular patients toward AD.Self-administered questionnaires were sent to general practitioners, cardiologists, internists, and intensivists, including the Quality of Communication Score, divided into a General Communication score (QOCgen 6 items) and an End-of-life Communication score (QOCeol 7 items), as well as questions regarding opinions and practices in terms of AD.One hundred sixty-four responses were received. QOCgen (mean (±SD)): 9.0/10 (1.0); QOCeol: 7.2/10 (1.7). General practitioners most frequently start discussions about AD (74/149 [47%]) and are more prone to designate their own specialty (30/49 [61%], P < 0.0001). Overall, only 57/159 (36%) physicians designated their own specialty; 130/158 (82%) physicians ask potential cardiovascular patients if they have AD and 61/118 (52%) physicians who care for cardiovascular patients talk about AD with some of them.The characteristics of physicians who do not talk about AD with patients were those who did not personally have AD and those who work in private practices.One hundred thirty-three (83%) physicians rated the systematic mention of patients' AD in the correspondence between physicians as good, while 114 (71%) at the patients' first registration in the private practice.Prehospital physicians rated their communication skills as good, whereas end-of-life communication was rated much lower. Only half of those surveyed speak about AD with cardiovascular patients. The majority would prefer that physicians of another specialty, most frequently general practitioners, initiate conversation about AD. In order to increase prehospital AD incidence, efforts must be centered on improving practitioners' communication skills regarding death, by providing trainings to allow physicians to feel more at ease when speaking about end-of-life issues.
预先医疗指示（AD）的制定是为了尊重患者的自主权。然而，即使是在即将进行重大心血管手术的情况下，也很少有患者拥有预先医疗指示。为了了解预先医疗指示普及率低的原因，并在患者无行为能力时帮助进行决策，有必要关注院前从业者的影响，他们可以通过与患者讨论预先医疗指示来促使其普及率提高。本研究的目的是调查可能参与心血管疾病患者护理的医生的自我评估沟通技巧以及他们对预先医疗指示的态度。
自行填写的问卷被发送给全科医生、心脏病专家、内科医生和重症监护医生，问卷包括沟通质量评分，分为一般沟通评分（QOCgen，6项）和临终沟通评分（QOCeol，7项），以及关于预先医疗指示的意见和做法的问题。
共收到164份回复。QOCgen（均值（±标准差））：9.0/10（1.0）；QOCeol：7.2/10（1.7）。全科医生最常开始关于预先医疗指示的讨论（74/149 [47%]），并且更倾向于指定自己的专业（30/49 [61%]，P＜0.0001）。总体而言，只有57/159（36%）的医生指定了自己的专业；130/158（82%）的医生会询问潜在的心血管疾病患者是否有预先医疗指示，61/118（52%）照顾心血管疾病患者的医生会与其中一些患者谈论预先医疗指示。
不与患者谈论预先医疗指示的医生的特点是那些自己没有预先医疗指示以及那些在私人诊所工作的医生。
133名（83%）医生认为在医生之间的通信中系统提及患者的预先医疗指示是好的，而在患者首次在私人诊所登记时，这一比例为114名（71%）。院前医生对自己的沟通技巧评价良好，而临终沟通的评价则低得多。只有一半的受访者会与心血管疾病患者谈论预先医疗指示。大多数人希望由另一个专业的医生，最常见的是全科医生，发起关于预先医疗指示的谈话。为了提高院前预先医疗指示的发生率，必须集中精力通过提供培训来提高从业者关于死亡的沟通技巧，以使医生在谈论临终问题时感觉更自在。
