Conducting Goals of Care Conversations: Lessons From the COVID-19 Pandemic.

IF 1.3 4区 医学 Q4 HEALTH CARE SCIENCES & SERVICES Journal of Palliative Care Pub Date : 2024-01-01 Epub Date: 2023-01-31 DOI:10.1177/08258597231153386
Alison T Lai, Nadine Abdullah
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Abstract

Objective: Internal medicine (IM) residents discuss a patient's goals of care (GOC) as part of their initial consultation. Residents have described inexperience, general discomfort, limited formal teaching, and prognostic uncertainty as barriers to effective GOC conversations. The early COVID-19 pandemic resulted in rapid changes to the healthcare system on the individual, patient, and systemic level that might exacerbate and/or introduce new barriers to IM residents' GOC conversations. This qualitative study examines how the early COVID-19 pandemic challenged IM residents' ability to have effective GOC conversations. Methods: Using a constructivist grounded theory approach, participants (n=11) completed a semi-structured interview. Data collection and analysis occurred simultaneously using an open coding, constant comparison process. Interviews were completed until no new themes were identified. Results: Residents self-described their GOC conversations in 5 steps: normalization of the conversation, introduction of expected clinical course, discussion of possible care plans, exploration of the patient's values, and occasionally providing a recommendation. Residents described limited structured teaching around GOC conversations and instead relied on observed role-modelling and self-practice to hone their skillset. Residents described an increased sense of urgency to have GOC conversations due to the uncertainty of clinical course and potential for rapid deterioration of patients with COVID-19. Residents identified restrictive visitor policies as a significant barrier that contributed to feelings of dehumanization. Residents felt that these limitations affected their GOC conversations and potentially resulted in discordant care plans which contributed to moral distress. Conclusion: The early COVID-19 pandemic resulted in several barriers that challenged residents' ability to conduct effective GOC conversations. This is on the background of previously reported discomfort and limited formal training in conducting GOC conversations. Based on our findings, we present a conceptual model involving teaching validated GOC frameworks, positive role-modelling, and experiential learning to support GOC conversation education in post-graduate medical education.

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开展护理目标对话:2019冠状病毒病大流行的教训。
目的:内科(IM)住院医师讨论患者的护理目标(GOC),作为其初步咨询的一部分。居民们将缺乏经验、普遍的不适、有限的正式教学和预后的不确定性描述为有效GOC对话的障碍。早期新冠肺炎大流行导致医疗系统在个人、患者和系统层面的快速变化,这可能会加剧和/或给IM居民的GOC对话带来新的障碍。这项定性研究考察了早期新冠肺炎大流行如何挑战IM居民进行有效GOC对话的能力。方法:采用建构主义理论方法,参与者(n=11)完成了一次半结构化访谈。数据收集和分析同时进行,使用开放编码、恒定比较过程。访谈已经完成,直到没有发现新的主题。结果:居民分5个步骤自我描述他们的GOC对话:对话的规范化、预期临床课程的介绍、可能的护理计划的讨论、对患者价值观的探索,以及偶尔提供建议。居民们描述了围绕GOC对话的有限结构化教学,而是依靠观察到的角色塑造和自我实践来磨练他们的技能。居民们表示,由于临床过程的不确定性和新冠肺炎患者快速恶化的可能性,进行GOC对话的紧迫感增强。居民们认为,限制性的游客政策是造成非人感的一个重要障碍。居民们认为,这些限制影响了他们的GOC对话,并可能导致不一致的护理计划,从而导致道德痛苦。结论:早期新冠肺炎大流行导致了一些障碍,这些障碍挑战了居民进行有效GOC对话的能力。这是在之前报道的不适和GOC对话的正式培训有限的背景下发生的。基于我们的研究结果,我们提出了一个概念模型,包括教学验证的GOC框架、积极的角色建模和体验式学习,以支持研究生医学教育中的GOC对话教育。
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来源期刊
Journal of Palliative Care
Journal of Palliative Care 医学-卫生保健
CiteScore
3.20
自引率
5.90%
发文量
63
审稿时长
>12 weeks
期刊介绍: The Journal of Palliative Care is a quarterly, peer-reviewed, international and interdisciplinary forum for practical, critical thought on palliative care and palliative medicine. JPC publishes high-quality original research, opinion papers/commentaries, narrative and humanities works, case reports/case series, and reports on international activities and comparative palliative care.
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