York Law School, The University of York, York, UK.
Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.
BMC Palliat Care. 2018 Mar 21;17(1):51. doi: 10.1186/s12904-018-0305-5.
Morbidity arising from unprepared bereavement is a problem that affects close personal relations of individuals at the end-of-life. The bereavement studies literature demonstrates that a lack of preparedness for a loved one's death is a risk factor for secondary psychological morbidity among survivors. Short awareness time of death negatively correlates to preparedness for bereavement. The absence of disclosure of end-of-life diagnosis and prognosis to close personal relations ('death talk') between patients and loved ones, or health professionals and loved ones, may contribute to short awareness time of death. To increase awareness time of death, we might attempt to increase patient first-personal disclosure of end-of-life diagnosis and prognosis to loved-ones, and/or patient consent to health professional disclosure of the same.
Interventions based on motivational interviewing in end-of-life care whose aim is to facilitate death talk, either by the patient directly, or by a health professional with the patient's consent, may offer a part solution to the problem of unprepared bereavement. This paper evaluates the ethical permissibility of such interventions. We consider two ethical objections to using motivational interviewing in this way: first, that it is inappropriate for practitioners to seek disclosure as an outcome in this setting; second, that aiming at disclosure risks manipulating individuals into death talk. While it need not be impermissible to direct individuals toward disclosure of end-of-life diagnosis/prognosis, the objection from manipulation implies that it is pro tanto ethically preferable to use motivational interviewing in a non-directive mode in death talk conversations. However, insofar as non-directive motivational interviewing requires more advanced skills, and thus may be more difficult to learn and to practise, we advance that it may be ethically permissible, all things considered, to employ directional, or specific outcome-oriented, motivational interviewing.
Motivational interviewing interventions in end-of-life care whose aim is to facilitate death talk, either by the patient directly, or by a health professional with the patient's consent may be ethically permissible, all things considered.
未做好准备而经历丧亲之痛会给临终患者的亲密关系人带来心理问题。丧亲研究文献表明，对亲人去世缺乏准备是幸存者出现继发性心理痛苦的一个风险因素。临终患者对死亡的认识时间越短，对丧亲的准备就越不充分。临终患者和其亲密关系人之间（“死亡谈话”），或者医患之间，未能公开临终诊断和预后，可能会导致临终患者对死亡的认识时间过短。为了增加临终患者对死亡的认识时间，我们可能会尝试增加患者向其亲密关系人第一人称披露临终诊断和预后的意愿，或者患者同意向医护人员披露同样的信息。
以促进“死亡谈话”为目的的临终关怀中的动机性访谈干预，无论是由患者直接进行，还是在获得患者同意的情况下由医护人员进行，都可能部分解决丧亲之痛准备不足的问题。本文评估了此类干预措施的伦理可接受性。我们考虑了在这种情况下使用动机性访谈的两个伦理反对意见：第一，从业者在这种情况下寻求披露是不适当的；第二，以披露为目标可能会将个人操纵成进行“死亡谈话”。虽然引导个人披露临终诊断/预后不一定是不道德的，但操纵的反对意见意味着，在“死亡谈话”对话中，以非引导性的方式使用动机性访谈在伦理上更可取。然而，由于非引导性的动机性访谈需要更高级的技能，因此可能更难学习和实践，我们认为，在全面考虑的情况下，采用定向的或特定结果导向的动机性访谈可能在伦理上是可以允许的。
以促进“死亡谈话”为目的的临终关怀中的动机性访谈干预，无论是由患者直接进行，还是在获得患者同意的情况下由医护人员进行，从全面考虑来看，可能在伦理上是可以允许的。
