临床医生在加拿大两个省份实施预先医疗指示路径的经验：一项定性研究。
Clinicians' experiences implementing an advance care planning pathway in two Canadian provinces: a qualitative study.
机构信息
End-of-Life Care Research Group, Vrije Universiteit Brussel, Laarkbeeklaan 103, Brussels, Belgium.
Department of Family Medicine, McMaster University, 1280 Main Street West, Hamilton, ON, Canada.
出版信息
BMC Prim Care. 2024 Jun 15;25(1):217. doi: 10.1186/s12875-024-02468-4.
BACKGROUND
Advance care planning (ACP) is a process which enables patients to communicate wishes, values, fears, and preferences for future medical care. Despite patient interest in ACP, the frequency of discussions remains low. Barriers to ACP may be mitigated by involving non-physician clinic staff, preparing patients ahead of visits, and using tools to structure visits. An ACP care pathway incorporating these principles was implemented in longitudinal generalist outpatient care, including primary care/family medicine and general internal medicine, in two Canadian provinces. This study aims to understand clinician experiences implementing the pathway.
METHODS
The pathway was implemented in one family practice in Alberta, two family practices in British Columbia (BC), and one BC internal medicine outpatient clinic. Physicians and allied health professionals delivered structured pathway visits based on the Serious Illness Conversation Guide. Twelve physicians and one social worker participated in interviews or focus groups at the end of the study period. Qualitative data were coded inductively using an iterative approach, with regular meetings between coders.
RESULTS
Clinicians described experiences with the ACP care pathway, impact at the clinician level, and impact at the patient level. Within each domain, clinicians described barriers and facilitators experienced during implementation. Clinicians also reflected candidly about potential for future implementation and the sustainability of the pathway.
CONCLUSIONS
While the pathway was implemented slightly differently between provinces, core experiences were that implementation of the pathway, and integration with current practice, were feasible. Across settings, similar themes recurred regarding usefulness of the pathway structure and its tools, impact on clinician confidence and interactions with patients, teamwork and task delegation, compatibility with existing workflow, and patient preparation and readiness. Clinicians were supportive of ACP and of the pathway.
TRIAL REGISTRATION
The study was prospectively registered with clinicaltrials.gov (NCT03508557). Registered April 25, 2018. https://classic.
CLINICALTRIALS
gov/ct2/show/NCT03508557 .
背景
预先医疗照护计划（ACP）是一个使患者能够传达其对未来医疗照护意愿、价值观、恐惧和偏好的过程。尽管患者对 ACP 感兴趣，但讨论的频率仍然很低。通过让非医师诊所工作人员参与、在就诊前为患者做好准备以及使用工具来组织就诊，可以减轻 ACP 的障碍。在加拿大的两个省份，在纵向通科门诊护理中实施了包含这些原则的 ACP 护理途径，包括初级保健/家庭医学和普通内科。本研究旨在了解临床医生实施该途径的经验。
方法
该途径在艾伯塔省的一个家庭诊所、不列颠哥伦比亚省的两个家庭诊所和一个不列颠哥伦比亚省的内科门诊诊所实施。医生和联合保健专业人员根据严重疾病对话指南提供结构化的途径就诊。在研究结束时，12 名医生和 1 名社会工作者参加了访谈或焦点小组。使用迭代方法对定性数据进行归纳编码，并定期在编码人员之间开会。
结果
临床医生描述了他们在 ACP 护理途径方面的经验、对临床医生层面的影响以及对患者层面的影响。在每个领域，临床医生都描述了在实施过程中遇到的障碍和促进因素。临床医生还坦率地反思了未来实施的潜力和途径的可持续性。
结论
尽管该途径在各省的实施方式略有不同，但核心经验是，该途径的实施以及与当前实践的整合是可行的。在所有环境中，关于途径结构及其工具的有用性、对临床医生信心和与患者互动的影响、团队合作和任务委托、与现有工作流程的兼容性以及患者准备和就绪情况的主题都相似。临床医生对 ACP 和途径表示支持。
试验注册
该研究前瞻性地在 clinicaltrials.gov 上注册（NCT03508557）。于 2018 年 4 月 25 日注册。https://classic.clinicaltrials.gov/ct2/show/NCT03508557。
临床试验
NCT03508557。
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