Morales Andre, Schultz Kevan C, Gao Shasha, Murphy Alan, Barnato Amber E, Fanning Joseph B, Hall Daniel E
Department of Medicine, Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
University Center for Social and Urban Research (UCSUR), University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
Palliat Med Rep. 2021 Mar 24;2(1):71-83. doi: 10.1089/pmr.2020.0054. eCollection 2021 Mar.
Goals of care discussions at the end of life give opportunity to affirm the autonomy and humanity of dying patients. Best practices exist for communication around goals of care, but there is no research on differences in approach taken by different specialties engaging these conversations. To describe the communication practices of internal medicine (IM), emergency medicine (EM), and critical care (CC) physicians in a high-fidelity simulation of a terminally ill patient with stable and defined end-of-life preferences. Mixed-methods secondary analysis of transcripts obtained from a multicenter study simulating high stakes, time-limited end-of-life decision making in a cohort of 88 volunteer physicians (27 IM, 22 EM, and 39 CC) who were called to evaluate a standardized patient in extremis. The patient had clear comfort-oriented goals of care that the physician needed to elicit and use to inform treatment decisions. Discussions were coded at the level of the sentence for semantic content. Data were analyzed by physician specialty. Occurrence of content codes indicative of prudent (right outcome by the right means) goals of care conversations. Data were analyzed both for number of occurrences of the code in a simulated conversation and for presence or absence of the code within a conversation. There was no difference between physician types in intubation rates or intensive care unit admissions. Codes for "comfort as a goal of care," "noncurative goals of care," and "oblique references to death" emerged as significantly different between physician types. This experiment shows demonstrable differences in practice patterns between physician specialties when addressing end-of-life decision making. Some of the variation likely arose from differences in setting, but these data suggest that training in goals of care conversations may benefit if it is adapted to the distinct needs and culture of each specialty.
临终关怀讨论的目标为确认临终患者的自主性和人性提供了契机。围绕关怀目标的沟通存在最佳实践方法，但对于不同专业在进行这些对话时所采用方法的差异，尚无相关研究。为了描述内科（IM）、急诊医学（EM）和重症监护（CC）医生在对一名临终偏好稳定且明确的绝症患者进行高保真模拟时的沟通实践。对从一项多中心研究获得的转录本进行混合方法二次分析，该研究模拟了88名志愿医生（27名内科医生、22名急诊医学医生和39名重症监护医生）参与的高风险、限时临终决策，这些医生被召集去评估一名处于危急状态的标准化患者。该患者有明确的以舒适为导向的关怀目标，医生需要引出这些目标并用于指导治疗决策。讨论内容按句子层面进行语义编码。数据按医生专业进行分析。出现表明审慎（通过正确手段达成正确结果）关怀目标对话的内容编码。对模拟对话中编码出现的次数以及对话中编码的有无均进行了数据分析。不同类型医生在插管率或重症监护病房收治率方面没有差异。“将舒适作为关怀目标”“非治愈性关怀目标”和“间接提及死亡”的编码在不同类型医生之间存在显著差异。这项实验表明，在处理临终决策时，不同医生专业的实践模式存在明显差异。部分差异可能源于环境不同，但这些数据表明，如果根据各专业的独特需求和文化对关怀目标对话培训进行调整，可能会有所助益。
