Cultures of Practice: Specialty-Specific Differences in End-of-Life Conversations.

Autor:	Morales A; Department of Medicine, Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, Nashville, Tennessee, USA., Schultz KC; University Center for Social and Urban Research (UCSUR), University of Pittsburgh, Pittsburgh, Pennsylvania, USA., Gao S; Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA., Murphy A; OhioHealth, Columbus, Ohio, USA., Barnato AE; Department of Medicine, The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA., Fanning JB; Department of Medicine, Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, Nashville, Tennessee, USA., Hall DE; Department of Surgery, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA.; Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
Jazyk:	angličtina
Zdroj:	Palliative medicine reports [Palliat Med Rep] 2021 Mar 24; Vol. 2 (1), pp. 71-83. Date of Electronic Publication: 2021 Mar 24 (Print Publication: 2021).
DOI:	10.1089/pmr.2020.0054
Abstrakt:	Importance: Goals of care discussions at the end of life give opportunity to affirm the autonomy and humanity of dying patients. Best practices exist for communication around goals of care, but there is no research on differences in approach taken by different specialties engaging these conversations. Objective: To describe the communication practices of internal medicine (IM), emergency medicine (EM), and critical care (CC) physicians in a high-fidelity simulation of a terminally ill patient with stable and defined end-of-life preferences. Design, Setting, and Participants: Mixed-methods secondary analysis of transcripts obtained from a multicenter study simulating high stakes, time-limited end-of-life decision making in a cohort of 88 volunteer physicians (27 IM, 22 EM, and 39 CC) who were called to evaluate a standardized patient in extremis. The patient had clear comfort-oriented goals of care that the physician needed to elicit and use to inform treatment decisions. Discussions were coded at the level of the sentence for semantic content. Exposures: Data were analyzed by physician specialty. Main Outcome Measure: Occurrence of content codes indicative of prudent (right outcome by the right means) goals of care conversations. Data were analyzed both for number of occurrences of the code in a simulated conversation and for presence or absence of the code within a conversation. Results: There was no difference between physician types in intubation rates or intensive care unit admissions. Codes for "comfort as a goal of care," "noncurative goals of care," and "oblique references to death" emerged as significantly different between physician types. Conclusions and Relevance: This experiment shows demonstrable differences in practice patterns between physician specialties when addressing end-of-life decision making. Some of the variation likely arose from differences in setting, but these data suggest that training in goals of care conversations may benefit if it is adapted to the distinct needs and culture of each specialty. Competing Interests: None of the authors have a conflict of interest. The opinions expressed in this study are those of the authors and do not necessarily reflect the position of the Department of Veterans Affairs or the U.S. government. (© Andre Morales et al., 2021; Published by Mary Ann Liebert, Inc.)
Databáze:	MEDLINE
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