Centre for Medical Ethics, Institute of Health and Society, Faculty of Medicine, University of Oslo, Postboks 1130, Blindern, 0318, Oslo, Norway.
Institute for Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo University Hospital, Oslo, Norway.
BMC Geriatr. 2023 Jun 23;23(1):387. doi: 10.1186/s12877-023-04060-4.
Advance care planning (ACP) is a way of applying modern medicine to the principle of patient autonomy and ensuring that patients receive medical care that is consistent with their values, goals and preferences. Robust evidence supports the benefits of ACP, but it remains an underutilized resource in most countries. This paper goes from the naïve point of view, and seeks to identify the barriers and facilitators to implementation in unfamiliarized contexts and in a whole system approach involving the clinical, institutional and policy level to improve the implementation of ACP.
Qualitative interviews were chosen to enable an explorative, flexible design. Qualitative interviews were conducted with 40 health care professionals and chief physicians in hospitals and in municipalities. The thematic analysis was done following Braun and Clarke's strategy for thematic analysis.
The main reported barriers were the lack of time and space, a lack of culture and leadership legitimizing ACP, lack of common communication systems, and unclear responsibility about who should initiate, resulting in missed opportunities and overtreatment. Policy development, public and professional education, and standardization of documentation were reported as key to facilitate ACP and build trust across the health care system.
Progressively changing the education of health professionals and the clinical culture are major efforts that need to be tackled to implement ACP in unfamiliarized contexts, particularly in contexts where patient's wishes are not legally binding. This will need to be tackled through rectifying the misconception that ACP is only about death, and providing practical training for health professionals, as well as developing policies and legislation on how to include patients and caregivers in the planning of care.
预先医疗照护计划（ACP）是将现代医学应用于患者自主权原则的一种方式，旨在确保患者得到符合其价值观、目标和偏好的医疗护理。强有力的证据支持 ACP 的益处，但在大多数国家，它仍然未得到充分利用。本文从一个天真的角度出发，试图在不熟悉的环境中，从临床、机构和政策层面的整体系统方法出发，确定实施 ACP 的障碍和促进因素，以改善 ACP 的实施。
选择定性访谈是为了实现探索性、灵活的设计。在医院和市政当局，对 40 名医疗保健专业人员和首席医师进行了定性访谈。主题分析遵循 Braun 和 Clarke 的主题分析策略进行。
报告的主要障碍是缺乏时间和空间、缺乏文化和领导力来合法化 ACP、缺乏共同的沟通系统以及关于谁应该启动的责任不明确，导致错失机会和过度治疗。政策制定、公众和专业教育以及文档标准化被认为是促进 ACP 和在整个医疗保健系统中建立信任的关键。
逐步改变卫生专业人员的教育和临床文化是在不熟悉的环境中实施 ACP 的主要努力方向，特别是在患者意愿不具有法律约束力的环境中。这需要通过纠正 ACP 仅与死亡有关的误解，为卫生专业人员提供实际培训，以及制定关于如何让患者和护理人员参与护理计划的政策和立法来解决。
