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支撑癌症患者预先医疗照护计划的概念模型和作用机制:一项随机对照试验的系统评价。

The conceptual models and mechanisms of action that underpin advance care planning for cancer patients: A systematic review of randomised controlled trials.

机构信息

1 Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK.

2 Sussex Community NHS Foundation Trust, Brighton, UK.

出版信息

Palliat Med. 2019 Jan;33(1):5-23. doi: 10.1177/0269216318809582. Epub 2018 Oct 26.

Abstract

BACKGROUND

: No systematic review has focused on conceptual models underpinning advance care planning for patients with advanced cancer, and the mechanisms of action in relation to the intended outcomes.

AIM

: To appraise conceptual models and develop a logic model of advance care planning for advanced cancer patients, examining the components, processes, theoretical underpinning, mechanisms of action and linkage with intended outcomes.

DESIGN

: A systematic review of randomised controlled trials was conducted, and was prospectively registered on PROSPERO. Narrative synthesis was used for data analysis.

DATA SOURCES

: The data sources were MEDLINE, CINAHL, PsycINFO, EMBASE, CENTRAL, PROSPERO, CareSearch, and OpenGrey with reference chaining and hand-searching from inception to 31 March 2017, including all randomised controlled trials with advance care planning for cancer patients in the last 12 months of life. Cochrane quality assessment tool was used for quality appraisal.

RESULTS

: Nine randomised controlled trials were included, with only four articulated conceptual models. Mechanisms through which advance care planning improved outcomes comprised (1) increasing patients' knowledge of end-of-life care, (2) strengthening patients' autonomous motivation, (3) building patients' competence to undertake end-of-life discussions and (4) enhancing shared decision-making in a trustful relationship. Samples were largely highly educated Caucasian.

CONCLUSION

: The use of conceptual models underpinning the development of advance care planning is uncommon. When used, they identify the individual behavioural change. Strengthening patients' motivation and competence in participating advance care planning discussions are key mechanisms of change. Understanding cultural feasibility of the logic model for different educational levels and ethnicities in non-Western countries should be a research priority.

摘要

背景

目前尚无系统评价专门关注为晚期癌症患者制定的预先医疗照护计划背后的概念模型,以及这些模型与预期结果之间的作用机制。

目的

评价预先医疗照护计划的概念模型,并制定晚期癌症患者预先医疗照护计划的逻辑模型,检验其组成部分、过程、理论基础、作用机制以及与预期结果的联系。

设计

对随机对照试验进行系统评价,并在 PROSPERO 前瞻性注册。采用叙述性综合法进行数据分析。

资料来源

检索 MEDLINE、CINAHL、PsycINFO、EMBASE、CENTRAL、PROSPERO、CareSearch 和 OpenGrey 数据库,追溯纳入文献的参考文献,并手工检索,时间截止至 2017 年 3 月 31 日,纳入所有在癌症患者生命的最后 12 个月内实施的针对预先医疗照护计划的随机对照试验。采用 Cochrane 偏倚风险评估工具进行质量评价。

结果

共纳入 9 项随机对照试验,仅有 4 项明确阐述了概念模型。预先医疗照护计划改善结局的作用机制包括:(1)增加患者对临终关怀的了解;(2)增强患者的自主动机;(3)增强患者进行临终讨论的能力;(4)在信任关系中促进共同决策。研究对象样本主要为受教育程度较高的白种人。

结论

在预先医疗照护计划的制定中,使用概念模型的情况并不常见。在使用概念模型时,模型确定了个体行为的改变。增强患者参与预先医疗照护计划讨论的动机和能力是改变的关键机制。了解不同教育水平和种族的文化可行性,以及非西方国家的逻辑模型,应成为研究重点。

https://cdn.ncbi.nlm.nih.gov/pmc/blobs/1310/6291906/b0c5fbf6bcec/10.1177_0269216318809582-fig1.jpg

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