Division of Hospital Medicine, University of California, San Francisco, San Francisco, California, USA.
Institute of Health Policy Studies, University of California San Francisco, San Francisco, California, USA.
J Pain Symptom Manage. 2018 Feb;55(2):282-289.e1. doi: 10.1016/j.jpainsymman.2017.08.019. Epub 2017 Sep 1.
The American Medical System is programmed to a default setting of aggressive care for the terminally ill. Institutional norms of decision making have been shown to promote high-intensity care, regardless of consistency with patient preferences. There are myriad factors at a system, clinician, surrogate, and patient level that drive the culture of overly aggressive treatments in American hospitals.
The objective of this study was to understand physician perspective of the ways systems-level factors influence patient, physician, and surrogate perceptions and consequent behavior.
Semi-structured in-depth qualitative interviews with 42 internal medicine physicians across three American academic medical centers were conducted. This qualitative study was exploratory in nature, intended to enhance conceptual understanding of underlying phenomena that drive physician attitudes and behavior.
The interviews revealed many factors that contributed to overly aggressive treatments at the end of life. Systemic factors, which describe underlying cultures (including institutional, professional, or community-based cultures), typical practices of care, or systemic defaults that drive patterns of care, manifested its influence both directly and through its impact on patient, surrogate, and physician behaviors and attitudes.
Institutional cultures, social norms, and systemic defaults influence both normative beliefs regarding standards of care and treatments plans that may not benefit seriously ill patients.
美国医疗体系设定了默认的积极治疗绝症患者的方案。已证明机构决策规范会促进高强度治疗，而不考虑其是否符合患者的偏好。在系统、临床医生、代理人和患者层面上，有无数因素推动了美国医院过度积极治疗的文化。
本研究的目的是了解医生对系统层面因素影响患者、医生和代理人的看法以及由此产生的行为的看法。
在三家美国学术医疗中心对 42 名内科医生进行了半结构化深入定性访谈。这项定性研究具有探索性，旨在增强对驱动医生态度和行为的潜在现象的概念理解。
访谈揭示了许多导致生命末期过度积极治疗的因素。系统性因素描述了潜在的文化（包括机构、专业或社区文化）、典型的护理实践或驱动护理模式的系统默认值，这些因素通过对患者、代理人和医生的行为和态度的影响，直接或间接地产生影响。
机构文化、社会规范和系统默认值会影响关于护理标准和治疗计划的规范信念，这些信念可能对重病患者没有益处。
