Lagrotteria Andrew, Swinton Marilyn, Simon Jessica, King Seema, Boryski Gwenn, Ma Irene Wai Yan, Dunne Fiona, Singh Japteg, Bernacki Rachelle E, You John J
Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.
Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada.
JAMA Netw Open. 2021 Aug 2;4(8):e2121517. doi: 10.1001/jamanetworkopen.2021.21517.
Discussions about goals of care with patients who are seriously ill typically occur infrequently and late in the illness trajectory, are of low quality, and focus narrowly on the patient's resuscitation preferences (ie, code status), risking provision of care that is inconsistent with patients' values. The Serious Illness Care Program (SICP) is a multifaceted communication intervention that builds capacity for clinicians to have earlier, more frequent, and more person-centered conversations.
To explore clinicians' experiences with the SICP 1 year after implementation.
DESIGN, SETTING, AND PARTICIPANTS: This qualitative study was conducted at 2 tertiary care hospitals in Canada. The SICP was implemented at Hamilton General Hospital (Hamilton, Ontario) from March 1, 2017, to January 19, 2018, and at Foothills Medical Centre (Calgary, Alberta) from March 1, 2018, to December 31, 2020. A total of 45 clinicians were invited to participate in the study, and 23 clinicians (51.1%) were enrolled and interviewed. Semistructured interviews of clinicians were conducted between August 2018 and May 2019. Content analysis was used to evaluate information obtained from these interviews between May 2019 and May 2020.
The SICP includes clinician training, communication tools, and processes for system change.
Clinicians' experiences with and perceptions of the SICP.
Among 23 clinicians interviewed, 15 (65.2%) were women. The mean (SD) number of years in practice was 14.6 (9.1) at the Hamilton site and 12.0 (6.9) at the Calgary site. Participants included 19 general internists, 3 nurse practitioners, and 1 social worker. The 3 main themes were the ways in which the SICP (1) supported changes in clinician behavior, (2) shifted the focus of goals-of-care conversations beyond discussion of code status, and (3) influenced clinicians personally and professionally. Changes in clinician behavior were supported by having a unit champion, interprofessional engagement, access to copies of the Serious Illness Conversation Guide, and documentation in the electronic medical record. Elements of the program, especially the Serious Illness Conversation Guide, shifted the focus of goals-of-care conversations beyond discussion of code status and influenced clinicians on personal and professional levels. Concerns with the program included finding time to have conversations, building transient relationships, and limiting conversation fluidity.
In this qualitative study, hospital clinicians described components of the SICP as supporting changes in their behavior and facilitating meaningful patient interactions that shifted the focus of goals-of-care conversations beyond discussion of code status. The perceived benefits of SICP implementation stimulated uptake within the medical units. These findings suggest that the SICP may prompt hospital culture changes in goals-of-care dialogue with patients and the care of hospitalized patients with serious illness.
与重症患者讨论治疗目标的情况通常很少发生，且在疾病发展过程中较晚才进行，质量较低，并且狭隘地聚焦于患者的心肺复苏偏好（即抢救状态），这可能导致所提供的治疗与患者的价值观不一致。重症护理计划（SICP）是一项多方面的沟通干预措施，旨在增强临床医生进行更早、更频繁且更以患者为中心的对话的能力。
探讨临床医生在实施SICP一年后的体验。
设计、地点和参与者：这项定性研究在加拿大的两家三级护理医院进行。SICP于2017年3月1日至2018年1月19日在汉密尔顿综合医院（安大略省汉密尔顿）实施，并于2018年3月1日至2020年12月31日在山麓医疗中心（艾伯塔省卡尔加里）实施。共邀请了45名临床医生参与研究，23名临床医生（51.1%）登记并接受了访谈。2018年8月至2019年5月对临床医生进行了半结构化访谈。2019年5月至2020年5月采用内容分析法评估从这些访谈中获得的信息。
SICP包括临床医生培训、沟通工具和系统变革流程。
临床医生对SICP的体验和看法。
在接受访谈的23名临床医生中，15名（65.2%）为女性。汉密尔顿院区临床医生的平均（标准差）从业年限为14.6（9.1）年，卡尔加里院区为12.0（6.9）年。参与者包括19名普通内科医生、3名执业护士和1名社会工作者。三个主要主题是SICP（1）支持临床医生行为改变的方式，（2）将治疗目标对话的重点从讨论抢救状态转移，以及（3）对临床医生个人和职业的影响。临床医生行为的改变得到了科室负责人的支持、跨专业参与、获取《重症对话指南》副本以及电子病历中的记录。该计划的要素，尤其是《重症对话指南》，将治疗目标对话的重点从讨论抢救状态转移，并在个人和职业层面影响了临床医生。对该计划的担忧包括找时间进行对话、建立短暂的关系以及限制对话流畅性。
在这项定性研究中，医院临床医生将SICP的组成部分描述为支持他们行为的改变，并促进有意义的患者互动，从而将治疗目标对话的重点从讨论抢救状态转移。实施SICP的感知益处促使其在医疗科室中得到采用。这些发现表明SICP可能促使医院在与患者的治疗目标对话以及对重症住院患者的护理方面的文化变革。
