Wichmann Anne B, van Dam Hanna, Thoonsen Bregje, Boer Theo A, Engels Yvonne, Groenewoud A Stef
Radboud Institute for Health Sciences, IQ healthcare, Radboud university medical center, Nijmegen, The Netherlands.
Department of Anesthesiology, Pain and Palliative Medicine, Radboud university medical center, Nijmegen, The Netherlands.
BMC Fam Pract. 2018 Nov 28;19(1):184. doi: 10.1186/s12875-018-0868-5.
Although it is often recommended that general practitioners (GPs) initiate advance care planning (ACP), little is known about their experiences with ACP. This study aimed to identify GP experiences when conducting ACP conversations with palliative patients, and what factors influence these experiences.
Dutch GPs (N = 17) who had participated in a training on timely ACP were interviewed. Data from these interviews were analysed using direct content analysis.
Four themes were identified: ACP and society, the GP's perceived role in ACP, initiating ACP and tailor-made ACP. ACP was regarded as a 'hot topic'. At the same time, a tendency towards a society in which death is not a natural part of life was recognized, making it difficult to start ACP discussions. Interviewees perceived having ACP discussions as a typical GP task. They found initiating and timing ACP easier with proactive patients, e.g. who are anxious of losing capacity, and much more challenging when it concerned patients with COPD or heart failure. Patients still being treated in hospital posed another difficulty, because they often times are not open to discussion. Furthermore, interviewees emphasized that taking into account changing wishes and the fact that not everything can be anticipated, is of the utmost importance. Moreover, when patients are not open to ACP, at a certain point it should be granted that choosing not to know, for example about where things are going or what possible ways of care planning might be, is also a form of autonomy.
ACP currently is a hot topic, which has favourable as well as unfavourable effects. As GPs experience difficulties in initiating ACP if patients are being treated in the hospital, future research could focus on a multidisciplinary ACP approach and the role of medical specialists in ACP. Furthermore, when starting ACP with palliative patients, we recommend starting with current issues. In doing so, a start can be made with future issues kept in view. Although the tension between ACP's focus on the patient's direction and the right not to know can be difficult, ACP has to be tailored to each individual patient.
尽管通常建议全科医生（GP）开展预立医疗计划（ACP），但对于他们在ACP方面的经历却知之甚少。本研究旨在确定全科医生与姑息治疗患者进行ACP对话时的经历，以及哪些因素会影响这些经历。
对参加过及时ACP培训的荷兰全科医生（N = 17）进行了访谈。使用直接内容分析法对这些访谈的数据进行了分析。
确定了四个主题：ACP与社会、全科医生在ACP中所感知的角色、启动ACP和量身定制的ACP。ACP被视为一个“热门话题”。与此同时，人们认识到有一种倾向，即认为死亡不是生活的自然组成部分的社会，这使得启动ACP讨论变得困难。受访者将进行ACP讨论视为全科医生的一项典型任务。他们发现，对于积极主动的患者，例如担心失去行为能力的患者，启动和安排ACP更容易，而对于慢性阻塞性肺疾病（COPD）或心力衰竭患者则更具挑战性。仍在住院治疗的患者带来了另一个困难，因为他们通常不愿意进行讨论。此外，受访者强调，考虑到患者不断变化的愿望以及并非所有事情都能预料到这一事实至关重要。此外，当患者对ACP不开放时，在某个时候应该承认，选择不知道，例如事情的发展方向或可能的护理计划方式，也是一种自主形式。
目前，ACP是一个热门话题，既有有利影响也有不利影响。由于如果患者正在住院治疗，全科医生在启动ACP方面会遇到困难，未来的研究可以集中在多学科的ACP方法以及医学专家在ACP中的作用上。此外，在与姑息治疗患者开始ACP时，我们建议从当前问题入手。这样做的同时，可以着眼于未来问题。尽管ACP关注患者的方向与不知道的权利之间的紧张关系可能很棘手，但ACP必须针对每个患者量身定制。
