Taylor Paul, Johnson Miriam J, Dowding Dawn Wendy
St Luke's Hospice, Sheffield, UK
School of Health and Related Research, The University of Sheffield, Sheffield, United Kingdom.
BMJ Support Palliat Care. 2020 Sep;10(3):e26. doi: 10.1136/bmjspcare-2018-001535. Epub 2018 Oct 18.
To improve the ability of clinical staff to recognise end of life in hospital inpatients dying as a result of cancer and heart failure, and to generate new hypotheses for further research.
This mixed-methods study used decision theory as a theoretical basis. It involved a parallel databases-convergent design, incorporating findings from previously published research, with equal priority to study groups and synthesis by triangulation. The individual arms were (1) a retrospective cohort study of 102 patients with cancer and 81 patients with heart failure in an acute trust in the North of England, and(2) a semistructured interview study of 19 healthcare professionals caring for the same patient groups.
The synthesis of findings demonstrated areas of agreement, partial agreement, silence and dissonance when comparing the cohort findings with the interview findings. Trajectories of change are identified as associated with poor prognosis in both approaches, but based on different parameters. Management of patients has a significant impact on decision-making. The decision process requires repeated, iterative assessments and may benefit from a multidisciplinary approach. Uncertainty is a defining characteristic of the overall process, and objective parameters only have a limited role in predicting end of life.
The role of uncertainty is important as a trigger for discussions and a defined stage in a patient's illness journey. This is consistent with current approaches to recognising irreversible deterioration in those with serious illness. This study contributes ongoing evidence that these concepts are vital for decision-making.
提高临床工作人员识别因癌症和心力衰竭而死亡的住院患者临终状态的能力，并为进一步研究提出新的假设。
这项混合方法研究以决策理论为理论基础。它采用了平行数据库收敛设计，纳入了先前发表的研究结果，研究组具有同等优先级，并通过三角测量法进行综合分析。各个分支包括：（1）对英格兰北部一家急性信托机构的102名癌症患者和81名心力衰竭患者进行回顾性队列研究；（2）对照顾相同患者群体的19名医护人员进行半结构化访谈研究。
在将队列研究结果与访谈结果进行比较时，结果综合显示出一致、部分一致、沉默和不一致的领域。两种方法都将变化轨迹确定为与预后不良相关，但基于不同的参数。患者管理对决策有重大影响。决策过程需要反复、迭代评估，多学科方法可能会有所帮助。不确定性是整个过程的一个决定性特征，客观参数在预测临终方面的作用有限。
不确定性作为引发讨论的因素以及患者疾病历程中一个明确阶段的作用很重要。这与当前识别重症患者不可逆转恶化的方法一致。这项研究提供了持续的证据，证明这些概念对决策至关重要。
