1 Division of Colorectal Surgery, Department of Surgery, University of Michigan , Ann Arbor, Michigan.
2 Division of Colorectal Surgery, Department of Surgery, Allegheny Health Network , Pittsburgh, Pennsylvania.
J Palliat Med. 2018 Jun;21(6):780-788. doi: 10.1089/jpm.2017.0470. Epub 2018 Mar 13.
Nearly 20% of colorectal cancer (CRC) patients present with potentially incurable (Stage IV) disease, yet their physicians do not integrate cancer treatment with palliative care. Compared with patients treated by primary providers, surgical patients with terminal diseases are significantly less likely to receive palliative or end-of-life care.
To describe surgeon perspectives on palliative and end-of-life care for patients with Stage IV CRCs.
This is a convergent mixed methods study using a validated survey instrument from the Critical Care Peer Workgroup of the Robert Wood Johnson Foundation's Promoting Excellence in End-of-Life Care Project with additional qualitative questions.
Participants were all current, nonretired members of the American Society of Colon and Rectal Surgeons.
Surgeon-perceived barriers to palliative and end-of-life care for patients with Stage IV CRCs were identified.
Among 131 Internet survey respondents (response rate 16.5%), 76.1% reported no formal education in palliative care, and specifically noted inadequate training in techniques to forgo life-sustaining measures (37.9%) and communication (42.7%). Over half (61.8%) of surgeons cited unrealistic expectations among patients and families as a barrier to care, which also limited discussion of palliation. At the system level, absence of documentation, appropriate processes, and culture hindered the initiation of palliative care. Thematic analysis of open-ended questions confirmed and extended these findings through the following major barriers to palliative and end-of-life care: (1) surgeon knowledge and training; (2) communication challenges; (3) difficulty with prognostication; (4) patient and family factors encompassing unrealistic expectations and discordant preferences; and (5) systemic issues including culture and lack of documentation and appropriate resources.
Generalizability is limited by the small sample size inherent to Internet surveys, which may contribute to selection bias.
Surgeons valued palliative and end-of-life care but reported multilevel barriers to its provision. These data will inform strategies to reduce these perceived barriers.
近 20%的结直肠癌（CRC）患者患有潜在不可治愈（IV 期）疾病，但他们的医生并未将癌症治疗与姑息治疗相结合。与由初级医疗服务提供者治疗的患者相比，患有终末期疾病的手术患者接受姑息治疗或临终关怀的可能性显著降低。
描述外科医生对 IV 期 CRC 患者姑息治疗和临终关怀的看法。
这是一项使用来自罗伯特伍德约翰逊基金会促进卓越临终关怀项目关键护理同行工作组的经过验证的调查工具的收敛混合方法研究，外加一些定性问题。
参与者均为美国结肠直肠外科学会现任、非退休成员。
确定外科医生认为 IV 期 CRC 患者姑息治疗和临终关怀的障碍。
在 131 名互联网调查应答者（应答率 16.5%）中，76.1%的人表示没有接受过姑息治疗方面的正规教育，特别提到在放弃维持生命措施（37.9%）和沟通（42.7%）方面的培训不足。超过一半（61.8%）的外科医生将患者和家属的不切实际的期望列为治疗障碍，这也限制了姑息治疗的讨论。在系统层面，缺乏记录、适当的流程和文化阻碍了姑息治疗的启动。对开放式问题的主题分析通过以下姑息治疗和临终关怀的主要障碍进一步证实和扩展了这些发现：（1）外科医生的知识和培训；（2）沟通挑战；（3）预后困难；（4）患者和家属因素包括不切实际的期望和不一致的偏好；（5）系统问题，包括文化以及缺乏记录和适当的资源。
互联网调查固有的小样本量限制了其推广性，可能导致选择偏倚。
外科医生重视姑息治疗和临终关怀，但报告了提供姑息治疗的多层次障碍。这些数据将为减少这些感知障碍的策略提供信息。
