痴呆症患者的预先医疗照护计划：针对全科医生的教育干预的过程评估。
Advance care planning with people with dementia: a process evaluation of an educational intervention for general practitioners.
机构信息
Department of IQ Healthcare, Radboudumc, Nijmegen, The Netherlands.
Department of primary and community care, Radboudumc, Nijmegen, The Netherlands.
出版信息
BMC Fam Pract. 2020 Sep 23;21(1):199. doi: 10.1186/s12875-020-01265-z.
BACKGROUND
General practitioners (GPs) are advised to offer advance care planning (ACP) to people with dementia (PWD). In a randomized controlled trial, an educational intervention for GPs aimed at initiating and optimizing ACP proved to be effective. During the intervention most GPs were accompanied by their practice nurse (PN). To provide insights into the intervention's successful components and what could be improved, we conducted a process evaluation and explored implementation, mechanisms of impact and contextual factors.
METHODS
We used the Medical Research Council guidance for process evaluations. Implementation was explored identifying reach and acceptability. We performed descriptive analyses of participants' characteristics; selection, inclusion and intervention attendance; a GP post-intervention survey on initiating ACP; a post intervention focus group with trainers of the intervention. Mechanisms of impact were explored identifying adoption and appropriateness. We used: participants' intervention ratings; a GP post-intervention survey on conducting ACP; ACP documentation in PWD's medical files; post-intervention interviews with PWD/FC dyads. All data was used to identify contextual factors.
RESULTS
The intervention was implemented by a small percentage of the total Dutch GP population invited, who mostly included motivated PWD/FC dyads with relatively little burden, and PWD with limited cognitive decline. The mechanisms of impact for GPs were: interactively learning to initiate ACP with training actors with a heterogeneous group of GPs and PNs. For PWD/FCs dyads, discussing non-medical preferences was most essential regarding their SDM experience and QoL. Some dyads however found ACP stressful and not feasible. Younger female GPs more often initiated ACP. Male PWD and those with mild dementia more often had had ACP. These characteristics and the safe and intimate training setting, were important contextual facilitators.
CONCLUSION
We recommend Interventions aimed at improving ACP initiation with PWD by GPs to include interactive components and discussion of non-medical preferences. A safe environment and a heterogeneous group of participants facilitates such interventions. However, in practice not all FC/PWD dyads will be ready to start. Therefore, it is necessary to check their willingness when ACP is offered.
背景
全科医生（GP）被建议为痴呆症患者（PWD）提供预先护理计划（ACP）。在一项随机对照试验中，针对 GP 开展的一项教育干预措施，旨在启动和优化 ACP，结果被证明是有效的。在干预过程中，大多数 GP 都由他们的执业护士（PN）陪同。为了深入了解干预措施的成功因素以及可以改进的地方，我们进行了一项过程评估，并探讨了实施、影响机制和背景因素。
方法
我们使用了医学研究委员会（MRC）的过程评估指南。实施情况通过可达性和可接受性进行了探索。我们对参与者的特征进行了描述性分析；选择、纳入和干预参与情况；GP 干预后关于启动 ACP 的调查；对干预培训师的干预后焦点小组。影响机制通过采用和适当性进行了探索。我们使用了：参与者的干预评价；GP 干预后关于进行 ACP 的调查；PWD 医疗档案中的 ACP 记录；干预后与 PWD/FC 对访谈。所有数据都用于确定背景因素。
结果
该干预措施仅由受邀的荷兰全科医生总数中的一小部分实施，这些 GP 大多包括积极性较高的 PWD/FC 对，他们的负担相对较小，且 PWD 的认知能力下降程度有限。GP 的影响机制是：与具有不同背景的 GP 和 PN 培训师一起互动学习如何启动 ACP。对于 PWD/FC 对，讨论非医疗偏好对于他们的决策支持体验和生活质量至关重要。然而，有些对则认为 ACP 有压力且不可行。年轻的女 GP 更经常启动 ACP。患有轻度痴呆的男性 PWD 更经常进行了 ACP。这些特征以及安全和亲密的培训环境是重要的促进因素。
结论
我们建议旨在通过 GP 提高 PWD 的 ACP 启动率的干预措施包括互动组件和非医疗偏好的讨论。安全的环境和具有不同背景的参与者有利于此类干预措施的开展。然而，在实践中，并非所有 FC/PWD 对都准备好开始 ACP。因此，在提供 ACP 时，有必要检查他们的意愿。
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