Childers Julie W, Back Anthony L, Tulsky James A, Arnold Robert M
University of Pittsburgh, Pittsburgh, PA; University of Washington, Seattle WA; Dana-Farber Cancer Institute, Boston, MA.
J Oncol Pract. 2017 Oct;13(10):e844-e850. doi: 10.1200/JOP.2016.018796. Epub 2017 Apr 26.
Conversations regarding goals of care with patients who have advanced cancer still occur too late, and oncologists say they lack the training to have these conversations effectively. Experts recommend a number of strategies when having these discussions, including discussing prognosis, responding to patient emotion, exploring values, and often making a recommendation for medical treatments that fit those values. To help learners, from residents to attending oncologists, learn these complex conversational skills, we have developed a framework with a mnemonic, REMAP: Reframe, Expect emotion, Map out patient goals, Align with goals, and Propose a plan. In the reframe step, the oncologist provides a big picture "headline" that lets the patient know things are in a different place. This is followed by actively attending to the patient's emotional response (expect emotion). Then, to map the patient's goals, the oncologist asks open-ended questions that are designed to help the patient think about the values that should guide his or her treatment. The oncologist then aligns with those values by explicitly reflecting them back to the patient. If the patient gives permission, the oncologist will then use those values to propose a medical plan that matches patient values. The processes underlying REMAP encourage oncologists and other clinicians to seek to understand and remain flexible, adapting their recommendations to what they hear from the patient, with ongoing revision based on the shared decision-making process. This will lead to patient-centered decisions that promote better end-of-life care.
与晚期癌症患者就治疗目标进行的沟通仍然为时过晚，肿瘤学家表示他们缺乏有效进行此类沟通的培训。专家们推荐了一些进行此类讨论的策略，包括讨论预后、回应患者情绪、探索价值观，并且通常要根据这些价值观推荐合适的医疗治疗方案。为了帮助从住院医生到主治肿瘤学家等学习者掌握这些复杂的沟通技巧，我们开发了一个带有记忆口诀的框架，即REMAP：重新构建、预期情绪、梳理患者目标、与目标保持一致、提出计划。在重新构建步骤中，肿瘤学家提供一个宏观的“概要”，让患者知道情况已有所不同。接下来要积极关注患者的情绪反应（预期情绪）。然后，为了梳理患者的目标，肿瘤学家会提出开放式问题，旨在帮助患者思考应指导其治疗的价值观。肿瘤学家随后通过向患者明确反馈这些价值观来与之一致。如果患者给予许可，肿瘤学家随后将利用这些价值观提出一个与患者价值观相符的医疗计划。REMAP背后的流程鼓励肿瘤学家和其他临床医生努力去理解并保持灵活性，根据从患者那里听到的情况调整他们的建议，并基于共同决策过程不断进行修订。这将带来以患者为中心的决策，从而促进更好的临终关怀。
