Crawford Gregory Brian, Hodgetts Katherine, Burgess Teresa, Eliott Jaklin
Northern Adelaide Local Health Network, C/- Modbury Hospital, Smart Road, Modbury, 5092, Australia.
Discipline of Medicine, University of Adelaide, Adelaide, 5005, Australia.
BMC Palliat Care. 2021 Sep 9;20(1):138. doi: 10.1186/s12904-021-00838-8.
Advance care planning involves the discussion and documentation of an individual's values and preferences to guide their future healthcare should they lose capacity to make or communicate treatment decisions. Advance care planning can involve the individual's completion of an Advance Care Directive (ACD), a legislated and common-law instrument which may include appointment of a substitute decision-maker and binding refusals of treatment. In South Australia, ACDs intersect in the acute-care context with the Resuscitation Plan 7-Step Pathway (7-SP), an integrated care plan written for and by clinicians, designed to organise and improve patients' end-of-life care through the use of structured documentation. Here, we examine the perspectives of healthcare professionals (HCPs) within a hospital setting on the practical integration of ACDs and the 7-SP, exploring the perceived role, function, and value of each as they intersect to guide end-of-life care in an Australian hospital setting.
Qualitative data were collected via eight focus groups with a total of 74 HCPs (acute care, and oncology specialists; medical intern; general and emergency nurses; social workers) across two hospitals. Audio recordings were transcribed and thematically analysed.
HCPs viewed ACDs as a potentially valuable means of promoting patient autonomy, but as rarely completed and poorly integrated into hospital systems. Conversely, the process and documentation of the 7-SP was perceived as providing clarity about clinicians' responsibilities, and as a well-understood, integrated resource. Participants sometimes exhibited uncertainty around which document takes precedence if both were present. Sometimes, the routinisation of the 7-SP meant it was understood as the 'only way' to determine patient wishes and provide optimal end-of-life care. When this occurs, the perceived authority of ACDs, or of patients' choice not to participate in end-of-life discussions, may be undermined.
The intersection of ACDs and the 7-SP appears problematic within acute care. Clinicians' uncertainty as to whether an ACD or 7-SP takes precedence, and when it should do so, suggests a need for further clarity and training on the roles of these documents in guiding clinical practice, the legislative context within which specific documentation is embedded, and the dynamics associated with collaborative decision-making in end-of-life care.
预立医疗计划涉及对个人价值观和偏好的讨论与记录，以便在其丧失做出或传达治疗决策的能力时指导未来的医疗护理。预立医疗计划可能包括个人填写预立医疗指示（ACD），这是一种法律和普通法认可的文书，可能包括指定替代决策者以及具有约束力的拒绝治疗声明。在南澳大利亚州，急性护理环境中的预立医疗指示与复苏计划七步法（7-SP）相互关联，7-SP是一份由临床医生为患者编写并供其使用的综合护理计划，旨在通过结构化文档来组织和改善患者的临终护理。在此，我们研究医院环境中医护人员对预立医疗指示和7-SP实际整合的看法，探讨二者在澳大利亚医院环境中相互交叉以指导临终护理时各自被感知到的作用、功能和价值。
通过在两家医院与总共74名医护人员（急性护理和肿瘤专科医生、实习医生、普通和急诊护士、社会工作者）进行的八个焦点小组收集定性数据。对录音进行转录并进行主题分析。
医护人员认为预立医疗指示是促进患者自主性的潜在有价值手段，但很少有人填写，且很少融入医院系统。相反，7-SP的流程和文档被认为明确了临床医生的职责，是一种大家都理解的综合资源。如果两者都存在，参与者有时会对以哪个文件为准表现出不确定性。有时，7-SP的常规化意味着它被视为确定患者意愿并提供最佳临终护理的“唯一方式”。当这种情况发生时，预立医疗指示的权威性或患者选择不参与临终讨论的权利可能会受到损害。
在急性护理中，预立医疗指示和7-SP的交叉似乎存在问题。临床医生对于预立医疗指示还是7-SP优先以及何时优先存在不确定性，这表明需要进一步明确并培训这些文件在指导临床实践中的作用、特定文档所嵌入的法律背景以及临终护理中协作决策的相关动态。
