Department of Surgery, University of Wisconsin, Madison, Wisconsin, USA.
Center for Healthcare Outcomes and Policy, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA.
J Pain Symptom Manage. 2019 Jun;57(6):1080-1088.e1. doi: 10.1016/j.jpainsymman.2019.01.018. Epub 2019 Feb 10.
Palliative care services (PCS) are underutilized and frequently delayed among surgical patients. Surgical residents often serve at the forefront for patient issues, including conducting conversations regarding prognosis and goals of care.
This qualitative study identifies critical barriers to palliative care referral among seriously ill surgical patients from the perspective of surgical residents.
We conducted semistructured interviews with surgical residents (n = 18) across the state of Michigan, which focused on experiences with seriously ill surgical patients and PCS. Inductive thematic analysis was used to establish themes based on the research objectives and data collected.
Four dominant themes of resident-perceived barriers to palliative care referral were identified: 1) challenges with prognostication, 2) communication barriers, 3) respect for the surgical hierarchy, and 4) surgeon mentality. Residents consistently expressed challenges in predicting patient outcomes, and verbalizing this to both attendings and families augmented this uncertainty in seeking PCS. Communicative challenges included managing discordant provider opinions and the stigma associated with PCS. Finally, residents perceived that an attending surgeon's decisive authority and mentality negatively influenced the delivery of PCS.
Among resident trainees, unpredictable patient outcomes led to uncertainty in the timing and appropriateness of palliative care referral and further complicated communicating plans of care. Residents perceived and relied on the attending surgeon as the ultimate decision maker, wherein the surgeon's sense of responsibility to the patient was identified as a significant barrier to PCS referral. Further studies are needed to test surgeon-specific interventions to improve access to and delivery of PCS.
在外科患者中，姑息治疗服务（PCS）的利用率较低，且经常延迟。外科住院医师经常处于处理患者问题的最前线，包括就预后和护理目标进行对话。
本定性研究从外科住院医师的角度确定了重病外科患者接受姑息治疗转介的关键障碍。
我们在密歇根州对外科住院医师（n=18）进行了半结构化访谈，重点关注重病外科患者和 PCS 的经历。基于研究目标和收集的数据，采用归纳主题分析确定主题。
确定了居民认为姑息治疗转介的四个主要障碍主题：1）预后预测挑战，2）沟通障碍，3）尊重外科等级制度，和 4）外科医生心态。住院医师一致表示在预测患者预后方面存在挑战，并且向主治医生和家属表达这种不确定性会增加他们寻求 PCS 的不确定性。沟通障碍包括管理意见不一致的提供者和与 PCS 相关的耻辱感。最后，住院医师认为主治医生的果断权威和心态对 PCS 的提供产生了负面影响。
在住院医师培训中，不可预测的患者预后导致对姑息治疗转介的时机和适当性产生不确定性，进一步使沟通护理计划变得复杂。住院医师认为并依赖主治医生作为最终决策者，其中医生对患者的责任感被确定为姑息治疗转介的一个重要障碍。需要进一步的研究来测试针对外科医生的干预措施，以改善姑息治疗的获取和提供。
