O'Connor Moira, Watts Kaaren J, Kilburn Warren D, Vivekananda Kitty, Johnson Claire E, Keesing Sharon, Halkett Georgia K B, Shaw Josephine, Colgan Valerie, Yuen Kevin, Jolly Renate, Towler Simon C, Chauhan Anupam, Nicoletti Margherita, Leonard Anton D
WA Cancer Prevention Research Unit, School of Psychology, Faculty of Health Sciences, Curtin University, Perth, WA, Australia.
School of Psychological Sciences, Faculty of Education, Monash University, Melbourne, VIC, Australia.
J Gen Intern Med. 2020 Dec;35(12):3572-3580. doi: 10.1007/s11606-020-06233-y. Epub 2020 Oct 9.
Goals of care (GOC) is a communication and decision-making process that occurs between a clinician and a patient (or surrogate decision-maker) during an episode of care to facilitate a plan of care that is consistent with the patient's preferences and values. Little is known about patients' experiences of these discussions.
This study explored patients' perspectives of the GOC discussion in the hospital setting.
An explorative qualitative design was used within a social constructionist framework.
Adult patients were recruited from six Australian hospitals across two states. Eligible patients had had a GOC discussion and they were identified by the senior nurse or their doctor for informed consent and interview.
Semi-structured individual or dyadic interviews (with the carer/family member present) were conducted at the bedside or at the patient's home (for recently discharged patients). Interviews were audio-recorded and transcribed verbatim. Data were analysed for themes.
Thirty-eight patient interviews were completed. The key themes identified were (1) values and expectations, and (2) communication (sub-themes: (i) facilitators of the conversation, (ii) barriers to the conversation, and (iii) influence of the environment). Most patients viewed the conversation as necessary and valued having their preferences heard. Effective communication strategies and a safe, private setting were facilitators of the GOC discussion. Deficits in any of these key elements functioned as a barrier to the process.
Effective communication, and patients' values and expectations set the stage for goals of care discussions; however, the environment plays a significant role. Communication skills training and education designed to equip clinicians to negotiate GOC interactions effectively are essential. These interventions must also be accompanied by systemic changes including building a culture supportive of GOC, clear policies and guidelines, and champions who facilitate uptake of GOC discussions.
护理目标（GOC）是临床医生与患者（或替代决策者）在护理过程中进行的沟通和决策过程，以促成与患者偏好和价值观相符的护理计划。对于患者在这些讨论中的体验知之甚少。
本研究探讨了患者对医院环境中GOC讨论的看法。
在社会建构主义框架内采用探索性定性设计。
从两个州的六家澳大利亚医院招募成年患者。符合条件的患者进行过GOC讨论，由高级护士或其医生确定其为知情同意并接受访谈。
在床边或患者家中（针对近期出院患者）进行半结构化的个人或二元访谈（有护理人员/家庭成员在场）。访谈进行录音并逐字转录。对数据进行主题分析。
完成了38次患者访谈。确定的关键主题为：（1）价值观和期望，以及（2）沟通（子主题：（i）对话促进因素，（ii）对话障碍，以及（iii）环境的影响）。大多数患者认为这种对话是必要的，并且重视自己的偏好被倾听。有效的沟通策略以及安全、私密的环境是GOC讨论的促进因素。这些关键要素中任何一个的不足都会成为该过程的障碍。
有效的沟通以及患者的价值观和期望为护理目标讨论奠定了基础；然而，环境起着重要作用。旨在使临床医生有能力有效协商GOC互动的沟通技能培训和教育至关重要。这些干预措施还必须伴随系统性变革，包括营造支持GOC的文化、明确的政策和指南，以及促进GOC讨论实施的倡导者。
