Ethier Josee-Lyne, Paramsothy Thivaher, You John J, Fowler Robert, Gandhi Sonal
1 Department of Medical Oncology, Kingston General Hospital, Queen's University, Kingston, Ontario, Canada.
2 Division of Medical Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.
J Palliat Care. 2018 Jul;33(3):125-142. doi: 10.1177/0825859718762287. Epub 2018 Apr 2.
Earlier goals of care (GOC) discussions in patients with advanced cancer are associated with less aggressive end-of-life care including decreased use of medical technologies. Unfortunately, conversations often occur late in the disease trajectory when patients are acutely unwell. Here, we evaluate practitioner perspectives of patient, family, physician, and external barriers to early GOC discussions in the ambulatory oncology setting.
A previously published survey to assess barriers to GOC discussions among clinicians on inpatient medical wards was modified for the ambulatory oncology setting and distributed to oncologists from 12 centers in Ontario, Canada. Physicians were asked to rank the importance of various barriers to having GOC discussions (1 = extremely unimportant to 7 = extremely important).
Questionnaires were completed by 30 (24%) of 127 physicians. Respondents perceived patient- and family-related factors as the most important barriers to GOC discussions. Of these, patient difficulty accepting prognosis or desire for aggressive treatment were perceived as most important. Patients' inflated expectation of treatment benefit was also considered an important barrier to discontinuing active cancer-directed therapy. While physician barriers were ranked lower than patient-related factors, clinicians' self-identified difficulty estimating prognosis and uncertainty regarding treatment benefits were also considered important. Patient's refusal for referral was the most highly rated barrier to early palliative care referral. Most respondents were nonetheless very or extremely willing to initiate (90%) or lead (87%) GOC discussions.
Oncologists ranked patient- and family-related factors as the most important barriers to GOC discussions, while clinicians' self-identified difficulty estimating prognosis and uncertainty regarding treatment benefits were also considered important. Further work is required to assess patient preferences and perceptions and develop targeted interventions.
晚期癌症患者早期的医疗照护目标（GOC）讨论与减少积极的临终关怀相关，包括减少医疗技术的使用。不幸的是，这类对话往往在疾病进程后期患者病情严重时才进行。在此，我们评估了从业者对于门诊肿瘤环境中早期GOC讨论的患者、家庭、医生及外部障碍的看法。
一项先前发表的用于评估住院内科病房临床医生进行GOC讨论的障碍的调查，针对门诊肿瘤环境进行了修改，并分发给加拿大安大略省12个中心的肿瘤学家。医生被要求对进行GOC讨论的各种障碍的重要性进行排序（1 = 极不重要至7 = 极其重要）。
127名医生中有30名（24%）完成了问卷。受访者认为与患者和家庭相关的因素是GOC讨论最重要的障碍。其中，患者难以接受预后或渴望积极治疗被认为是最重要的。患者对治疗益处的过高期望也被视为停止积极的癌症导向治疗的重要障碍。虽然医生方面的障碍排名低于与患者相关的因素，但临床医生自我认定的预后评估困难以及治疗益处的不确定性也被认为很重要。患者拒绝转诊是早期姑息治疗转诊的最高评级障碍。尽管如此，大多数受访者非常愿意或极其愿意发起（90%）或主导（87%）GOC讨论。
肿瘤学家将与患者和家庭相关的因素列为GOC讨论最重要的障碍，而临床医生自我认定的预后评估困难以及治疗益处的不确定性也被认为很重要。需要进一步开展工作来评估患者的偏好和看法，并制定有针对性的干预措施。
