School of Public Health and Primary Care, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong.
School of Public Health and Primary Care, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong.
J Am Med Dir Assoc. 2017 Dec 1;18(12):1000-1009.e4. doi: 10.1016/j.jamda.2017.04.010. Epub 2017 Jun 13.
To inform health system improvements for care of elderly populations approaching the end of life (EOL) by identifying important elements of care and implementation barriers and facilitators.
A scoping review was carried out to identify key themes in EOL care. Articles were identified from MEDLINE, the Cochrane Library, organizational websites, and internet searches. Eligible publications included reviews, reports, and policy documents published between 2005 and 2016. Initially, eligible documents included reviews or reports concerning effective or important models or components of EOL care in older populations, and evidence was thematically synthesized. Later, other documents were identified to contextualize implementation issues.
Thematic synthesis using 35 reports identified key features in EOL care: (1) enabling policies and environments; (2) care pathways and models; (3) assessment and prognostication; (4) advance care planning and advance directives; (5) palliative and hospice care; (6) integrated and multidisciplinary care; (7) effective communication; (8) staff training and experience; (9) emotional and spiritual support; (10) personalized care; and (11) resources. Barriers in implementing EOL care include fragmented services, poor communication, difficult prognostication, difficulty in accepting prognosis, and the curative focus in medical care.
Quality EOL care for older populations requires many core components but the local context and implementation issues may ultimately determine if these elements can be incorporated into the system to improve care. Changes at the macro-level (system/national), meso-level (organizational), and micro-level (individual) will be required to successfully implement service changes to provide holistic and person-centered EOL care for elderly populations.
通过确定临终关怀的重要护理要素、实施障碍和促进因素，为改善老年人临终关怀医疗体系提供信息。
开展了范围综述，以确定临终关怀的关键主题。从 MEDLINE、Cochrane 图书馆、组织网站和互联网搜索中确定了符合条件的文章。符合条件的出版物包括 2005 年至 2016 年期间发表的综述、报告和政策文件。最初，符合条件的文件包括关于老年人群体中临终关怀有效或重要模式或组成部分的综述或报告，对证据进行了主题综合分析。后来，又确定了其他文件以了解实施问题的背景。
使用 35 份报告进行的主题综合分析确定了临终关怀的关键特征：（1）有利的政策和环境；（2）护理途径和模式；（3）评估和预测；（4）预先护理计划和预先指示；（5）姑息治疗和临终关怀；（6）综合和多学科护理；（7）有效沟通；（8）员工培训和经验；（9）情感和精神支持；（10）个性化护理；（11）资源。实施临终关怀的障碍包括服务分散、沟通不良、预测困难、难以接受预测结果以及医疗保健中的治疗重点。
为老年人群提供高质量的临终关怀需要许多核心要素，但当地情况和实施问题最终可能决定是否可以将这些要素纳入系统，以改善护理。需要在宏观层面（系统/国家）、中观层面（组织）和微观层面（个人）进行变革，以成功实施服务变革，为老年人群提供整体和以患者为中心的临终关怀。
