Mendoza Roger Lee
School of Business, Wilmington University, New Castle, Delaware, USA.
Int J Evid Based Healthc. 2017 Sep;15(3):111-120. doi: 10.1097/XEB.0000000000000105.
Now considered a subspecialty of medicine and nursing, palliative care is a critical aspect of healthcare at the end of life. National and international healthcare agencies typically attribute its slow or haphazard growth in developing countries to various resource constraints. However, this study provides evidence of the substantial and widening gap between policy advocacy and patient choices in end-of-life care. It does so by establishing the incentives and risks that underlie decision-making by patients and providers against the relative scarcity of palliative care and hospices in these countries.
Jamaica offers an illustrative case. It shares the socioeconomic conditions and isolated provision of hospice and palliative care that remain prevalent in many developing countries. Empirical information was collected from all Jamaican hospices, along with agency and media reports, for comparative institutional analysis.
Financial and infrastructural challenges hamper hospice expansion and integration into formal healthcare systems in developing countries. Yet, other equally vital considerations are too often neglected. These include the high transaction costs of decision-making, which account for limited hospice accessibility, affordability, and efficiency, particularly to underserved populations. Risk and payoff calculations by patients and their families as well as hospices and their providers lead to two strategic options in maximizing hospice value and/or minimizing transaction costs in end-of-life care.
Policy formulation and advocacy for hospice and palliative care should match aggregate demand. The socio-cultural milieu of care is critical and should be equally considered. Otherwise, providing and expanding free or subsidized palliative care at the end-of-life stage can become cost-inefficient relative to robust family and grassroots community networks.
姑息治疗如今被视为医学和护理的一个亚专业，是临终医疗保健的一个关键方面。国家和国际医疗保健机构通常将其在发展中国家增长缓慢或随意归因于各种资源限制。然而，本研究提供了证据，表明在临终关怀方面政策倡导与患者选择之间存在巨大且不断扩大的差距。该研究通过确定患者和提供者在这些国家姑息治疗和临终关怀相对稀缺的情况下进行决策所依据的激励因素和风险来做到这一点。
牙买加提供了一个具有代表性的案例。它具有许多发展中国家仍然普遍存在得社会经济状况以及临终关怀和姑息治疗的孤立提供情况。从牙买加所有临终关怀机构收集了实证信息，并结合机构和媒体报道进行比较制度分析。
财务和基础设施方面的挑战阻碍了发展中国家临终关怀机构的扩张以及将其纳入正式医疗保健系统。然而，其他同样重要的因素却常常被忽视。这些因素包括决策的高交易成本，这导致临终关怀机构的可及性、可负担性和效率有限，尤其是对服务不足的人群而言。患者及其家属以及临终关怀机构及其提供者的风险和回报计算导致了在临终关怀中最大化临终关怀价值和/或最小化交易成本的两种战略选择。
临终关怀和姑息治疗的政策制定与倡导应与总体需求相匹配。护理的社会文化环境至关重要，也应得到同等考虑。否则，相对于强大的家庭和基层社区网络，在临终阶段提供和扩大免费或补贴的姑息治疗可能会变得成本低效。
