The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA; Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA; Department of Computer Science, Dartmouth College, Hanover, NH, USA.
The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA; Section of Palliative Care, Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.
Soc Sci Med. 2022 Jul;305:115069. doi: 10.1016/j.socscimed.2022.115069. Epub 2022 May 30.
The diffusion of palliative care has been rapid, yet uncertainty remains regarding palliative care's "active ingredients." The National Consensus Project Guidelines for Quality Palliative Care identified eight domains of palliative care. Despite these identified domains, when pressed to describe the specific maneuvers used in clinical encounters, palliative care providers acknowledge that "it's complex." The field of systems has been used to explain complexity across many different types of systems. Specifically, engineering systems develop a representation of a system that helps manage complexity to help humans better understand the system. Our goal was to develop a system model of what palliative care providers do such that the elements of the model can be described concretely and sequentially, aggregated to describe the high-level domains currently described by palliative care, and connected to the complexity described by providers and the literature. Our study design combined methodological elements from both qualitative research and systems engineering modeling. The model drew on participant observation and debriefing semi-structured interviews with interdisciplinary palliative care team members by a systems engineer. The setting was an interdisciplinary palliative care service in a US rural academic medical center. In the developed system model, we identified 59 functions provided to patients, families, non-palliative care provider(s), and palliative care provider(s). The high-level functions related to measurement, decision-making, and treatment address up to 8 states of an individual, including an overall holistic state, physical state, psychological state, spiritual state, cultural state, personal environment state, and clinical environment state. In contrast to previously described expert consensus domain-based descriptions of palliative care, this model more directly connects palliative care provider functions to emergent behaviors that may explain system-level mechanisms of action for palliative care. Thus, a systems modeling approach provides insights into the challenges surrounding the recurring question of what is in the palliative care "syringe."
缓和医疗的传播速度很快，但缓和医疗的“有效成分”仍存在不确定性。《国家共识项目缓和医疗质量指南》确定了缓和医疗的八个领域。尽管有了这些确定的领域，但当被要求描述临床接触中使用的具体手法时，缓和医疗提供者承认“这很复杂”。系统领域已被用于解释许多不同类型系统的复杂性。具体来说，工程系统对系统进行了表示，以帮助管理复杂性，帮助人们更好地理解系统。我们的目标是开发一种缓和医疗提供者所做工作的系统模型，以便模型的元素可以具体和按顺序描述，聚合起来描述当前由缓和医疗描述的高级别领域，并与提供者和文献中描述的复杂性联系起来。我们的研究设计结合了定性研究和系统工程建模的方法元素。该模型借鉴了系统工程师对美国农村学术医疗中心跨学科缓和医疗服务团队成员的参与观察和事后半结构化访谈。在开发的系统模型中，我们确定了为患者、家属、非缓和医疗提供者和缓和医疗提供者提供的 59 项功能。与测量、决策和治疗相关的高级功能涉及到个人的 8 种状态，包括整体整体状态、身体状态、心理状态、精神状态、文化状态、个人环境状态和临床环境状态。与之前描述的缓和医疗专家共识基于领域的描述相比，该模型更直接地将缓和医疗提供者的功能与可能解释缓和医疗系统级作用机制的紧急行为联系起来。因此，系统建模方法提供了对缓和医疗“注射器”中存在的问题的深入了解。
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