Piili Reetta P, Lehto Juho T, Metsänoja Riina, Hinkka Heikki, Kellokumpu-Lehtinen Pirkko-Liisa I
Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
Department of Oncology, Palliative Unit, Tampere University Hospital, Tampere, Finland.
BMJ Support Palliat Care. 2019 Aug 8. doi: 10.1136/bmjspcare-2019-001802.
Physicians' decision-making in end-of-life (EOL) care includes many medical, ethical and juridical aspects. We studied the changes of these decisions over time and factors influencing them.
A postal survey including two hypothetical patient scenarios was sent to 1258 Finnish physicians in 2015 and to 1182 in 1999. The attitudes, values and background factors of the physicians were also enquired.
The response rate was 56%. The physicians' decisions to choose palliative approaches over active or intensive care increased from 1999 to 2015 when a terminally ill prostate cancer patient had probable iatrogenic gastrointestinal bleeding (53% vs 59%, p=0.014) and waited to meet his son (46% vs 60%, p<0.001) or a minister (53% vs 71%, p<0.001). Training in EOL care independently increased palliative approaches. Patient's benefit (96% vs 99%, p=0.001), ethical values (83% vs 93%, p<0.001) and patient's (68% vs 86%, p<0.001) or physician's (44% vs 63%, p<0.001) legal protection were considered more influential to the decisions in 2015, while the family's benefit was regarded as less influential to the decisions than it was in 1999 (37% vs 25%, p<0.001). Physicians were more willing to give a hospice voucher for an advanced breast cancer patient in 2015 (34% vs 58%, p<0.001).
Our findings may reflect the transition to a stronger emphasis on patient-centred care and a stronger tendency to avoid futile therapies that have only short-term goals. The results highlight that education in all aspects of EOL care should be incorporated into the post-graduate training of medical specialties that take care of dying patients.
医生在临终关怀中的决策包含许多医学、伦理和法律方面的内容。我们研究了这些决策随时间的变化以及影响它们的因素。
2015年向1258名芬兰医生邮寄了包含两个假设患者场景的调查问卷，1999年则邮寄给了1182名医生。同时还询问了医生的态度、价值观和背景因素。
回复率为56%。从1999年到2015年，当一名晚期前列腺癌患者可能发生医源性胃肠道出血（53%对59%，p = 0.014）、等待与儿子见面（46%对60%，p < 0.001）或与牧师见面（53%对71%，p < 0.001）时，医生选择姑息治疗而非积极或强化治疗的决策有所增加。临终关怀培训独立增加了姑息治疗方法的选择。2015年，患者的益处（96%对99%，p = 0.001）、伦理价值观（83%对93%，p < 0.001）以及患者（68%对86%，p < 0.001）或医生（44%对63%，p < 0.001）的法律保护被认为对决策更具影响力；而与1999年相比，家庭的益处被认为对决策的影响力较小（37%对25%，p < 0.001）。2015年，医生更愿意为晚期乳腺癌患者提供临终关怀代金券（34%对58%，p < 0.001）。
我们的研究结果可能反映了向更加强调以患者为中心的护理的转变，以及避免仅具有短期目标的无效治疗的更强倾向。结果表明，临终关怀各方面的教育应纳入照顾临终患者的医学专业研究生培训中。
