Horning Melanie A, Habermann Barbara
Department of Nursing, Towson University, 8000 York Road, Towson, MD 21252, USA.
School of Nursing, Pacific Lutheran University, Tacoma, WA, USA.
Palliat Care Soc Pract. 2024 Aug 1;18:26323524241264882. doi: 10.1177/26323524241264882. eCollection 2024.
Among the chronically ill, end-of-life conversations are often delayed until emergently necessary and the quality of those conversations and subsequent decision-making become compromised by critical illness, uncertainty, and anxiety. Many patients receive treatment that they would have declined if they had a better understanding of benefits and risks. Primary care providers are ideal people to facilitate end-of-life conversations, but these conversations rarely occur in the out-patient setting.
To investigate the self-reported experiences of physicians and advanced practice nurses with conversational barriers and facilitators while leading end-of-life discussions in the primary care setting.
A qualitative descriptive study.
Six physicians and eight advanced practice nurses participated in singular semi-structured interviews. Results were analyzed using a qualitative descriptive design and content analysis approach to coding.
Reported barriers in descending order included resistance from patients and families, insufficient time, and insufficient understanding of prognosis and associated expectations. Reported facilitators in descending order included established trusting relationship with provider, physical and/or cognitive decline and poor prognosis; and discussion standardization per Medicare guidelines.
Recommendations for improving the end-of-life conversational process in the primary care setting include further research regarding end-of-life conversational facilitators within families, the improvement of patient/family education about hospice/palliative care resources and examining the feasibility of longer appointment allotment..
在慢性病患者中，临终谈话往往会推迟到紧急需要时才进行，而这些谈话的质量以及随后的决策会因危重病、不确定性和焦虑而受到影响。许多患者接受了一些治疗，但如果他们对治疗的益处和风险有更好的了解，就会拒绝这些治疗。初级保健提供者是促进临终谈话的理想人选，但这些谈话在门诊环境中很少发生。
调查在初级保健环境中主导临终讨论时，医生和高级执业护士在谈话障碍和促进因素方面的自我报告经历。
一项定性描述性研究。
6名医生和8名高级执业护士参与了单独的半结构化访谈。使用定性描述性设计和内容分析编码方法对结果进行分析。
报告的障碍按降序排列包括患者和家属的抵触、时间不足以及对预后和相关期望的理解不足。报告的促进因素按降序排列包括与提供者建立的信任关系、身体和/或认知能力下降以及预后不良；以及根据医疗保险指南进行讨论标准化。
改善初级保健环境中临终谈话过程的建议包括进一步研究家庭内部的临终谈话促进因素、改善患者/家属对临终关怀/姑息治疗资源的教育，以及研究延长预约时间的可行性。
