Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine, Pontificia Universidad Javeriana, Bogota, Colombia.
Internal Medicine Resident, Faculty of Medicine, Pontificia Universidad Javeriana, Bogota, Colombia.
BMC Palliat Care. 2021 May 28;20(1):76. doi: 10.1186/s12904-021-00768-5.
In Colombia, recent legislation regarding end-of-life decisions includes palliative sedation, advance directives and euthanasia. We analysed which aspects influence health professionals´ decisions regarding end-of-life medical decisions and care for cancer patients.
Qualitative descriptive-exploratory study based on phenomenology using semi-structured interviews. We interviewed 28 oncologists, palliative care specialists, general practitioners and nurses from three major Colombian institutions, all involved in end-of-life care of cancer patients: Hospital Universitario San Ignacio and Instituto Nacional de Cancerología in Bogotá and Hospital Universitario San José in Popayan.
When making decisions regarding end-of-life care, professionals consider: 1. Patient's clinical condition, cultural and social context, in particular treating indigenous patients requires special skills. 2. Professional skills and expertise: training in palliative care and experience in discussing end-of-life options and fear of legal consequences. Physicians indicate that many patients deny their imminent death which hampers shared decision-making and conversations. They mention frequent ambiguity regarding who initiates conversations regarding end-of-life decisions with patients and who finally takes decisions. Patients rarely initiate such conversations and the professionals normally do not ask patients directly for their preferences. Fear of confrontation with family members and lawsuits leads healthcare workers to carry out interventions such as initiating artificial feeding techniques and cardiopulmonary resuscitation, even in the absence of expected benefits. The opinions regarding the acceptability of palliative sedation, euthanasia and use of medications to accelerate death without the patients´ explicit request vary greatly. 3. Conditions of the insurance system: limitations exist in the offer of oncology and palliative care services for important proportions of the Colombian population. Colombians have access to opioid medications, barriers to their application are largely in delivery by the health system, the requirement of trained personnel for intravenous administration and ambulatory and home care plans which in Colombia are rare.
To improve end-of-life decision making, Colombian healthcare workers and patients need to openly discuss wishes, needs and care options and prepare caregivers. Promotion of palliative care education and development of palliative care centres and home care plans is necessary to facilitate access to end-of-life care. Patients and caregivers' perspectives are needed to complement physicians' perceptions and practices.
在哥伦比亚，最近有关生命末期决策的立法包括缓和性镇静、预先指示和安乐死。我们分析了哪些因素影响卫生专业人员对癌症患者生命末期医疗决策和护理的决策。
基于现象学的定性描述性探索性研究，采用半结构式访谈。我们采访了来自哥伦比亚三家主要机构的 28 名肿瘤学家、姑息治疗专家、全科医生和护士，他们都参与了癌症患者的生命末期护理：波哥大的圣伊西德罗大学医院和国家癌症研究所以及帕皮亚扬的圣何塞大学医院。
在做出生命末期护理决策时，专业人员会考虑：1. 患者的临床状况、文化和社会背景，特别是治疗土著患者需要特殊技能。2. 专业技能和专业知识：接受姑息治疗培训以及在讨论生命末期选择和对法律后果的恐惧方面的经验。医生表示，许多患者否认自己即将死亡，这阻碍了共同决策和对话。他们提到，关于谁开始与患者讨论生命末期决策以及最终由谁做出决策，经常存在模糊性。患者很少主动发起此类对话，专业人员通常也不会直接询问患者的偏好。害怕与家属对抗和法律诉讼导致医护人员进行干预，例如启动人工喂养技术和心肺复苏，即使在没有预期获益的情况下也是如此。对于姑息性镇静、安乐死以及在没有患者明确要求的情况下使用加速死亡的药物的可接受性，意见差异很大。3. 保险制度的条件：对于相当一部分哥伦比亚人，提供肿瘤学和姑息治疗服务存在限制。哥伦比亚人可以获得阿片类药物，但在卫生系统中应用这些药物存在很大障碍，需要经过培训的人员进行静脉注射以及提供门诊和家庭护理计划，而这些在哥伦比亚很少见。
为了改善生命末期决策，哥伦比亚的医护人员和患者需要公开讨论意愿、需求和护理选择，并为护理人员做好准备。需要促进姑息治疗教育，发展姑息治疗中心和家庭护理计划，以方便获得生命末期护理。需要患者和护理人员的观点来补充医生的看法和做法。
