背景:尽早获得专业姑息治疗与更好的生活质量有关,晚期癌症患者的临终治疗强度较低,预后改善。然而,姑息治疗的实施和整合存在显著差异。本研究比较了组织,社会文化,以及支持或阻碍美国三个癌症中心姑息治疗整合的临床因素,采用深入混合方法的病例研究设计,并提出了一个中程理论来进一步表征专科姑息治疗整合。
方法:混合方法数据收集包括文件审查,半结构化面试,直接临床观察,以及与站点特征和患者人口统计相关的上下文数据。使用混合的归纳和演绎方法和三角测量来分析和比较站点姑息治疗交付模型,组织结构,社会规范,和临床医生的信念和实践。
结果:站点包括中西部的城市中心和东南部的两个。数据包括62名临床医生和27名领导访谈,对410次住院和门诊见面会和7次非见面会的观察,和多个文件。两个站点对专业姑息治疗整合具有高水平的“有利”组织影响力,包括筛查,政策,以及其他有助于将专业姑息治疗整合到晚期癌症治疗中的结构。第三个站点缺乏专业姑息治疗的正式组织政策和结构,有一个小型的专业姑息治疗小组,拥护与治疗创新相关的组织认同,并证明了肿瘤学家在决策中的首要地位。这种组合导致专业姑息治疗整合水平较低,并且更多地依赖个别临床医生来启动姑息治疗。
结论:晚期癌症护理中专业姑息治疗服务的整合与组织层面因素的复杂相互作用有关,社会规范,和个人临床医生的取向。由此产生的中程理论表明,专业姑息治疗的正式结构和政策与支持性社会规范相结合,与晚期癌症护理中更大的姑息治疗整合相关。以及个别临床医生偏好或继续治疗倾向的影响较小。这些结果表明,在不同层面进行了多方面的努力,包括社会规范,可能需要改善晚期癌症患者的专业姑息治疗整合。
BACKGROUND: Early access to specialty palliative care is associated with better quality of life, less intensive end-of-life treatment and improved outcomes for patients with advanced cancer. However, significant variation exists in implementation and integration of palliative care. This study compares the organizational, sociocultural, and clinical factors that support or hinder palliative care integration across three U.S. cancer centers using an in-depth mixed methods case study design and proposes a middle range theory to further characterize specialty palliative care integration.
METHODS: Mixed methods data collection included document review, semi-structured interviews, direct clinical observation, and context data related to site characteristics and patient demographics. A mixed inductive and deductive approach and triangulation was used to analyze and compare sites\' palliative care delivery models, organizational structures, social norms, and clinician beliefs and practices.
RESULTS: Sites included an urban center in the Midwest and two in the Southeast. Data included 62 clinician and 27 leader interviews, observations of 410 inpatient and outpatient encounters and seven non-encounter-based meetings, and multiple documents. Two sites had high levels of \"favorable\" organizational influences for specialty palliative care integration, including screening, policies, and other structures facilitating integration of specialty palliative care into advanced cancer care. The third site lacked formal organizational policies and structures for specialty palliative care, had a small specialty palliative care team, espoused an organizational identity linked to treatment innovation, and demonstrated strong social norms for oncologist primacy in decision making. This combination led to low levels of specialty palliative care integration and greater reliance on individual clinicians to initiate palliative care.
CONCLUSIONS: Integration of specialty palliative care services in advanced cancer care was associated with a complex interaction of organization-level factors, social norms, and individual clinician orientation. The resulting middle range theory suggests that formal structures and policies for specialty palliative care combined with supportive social norms are associated with greater palliative care integration in advanced cancer care, and less influence of individual clinician preferences or tendencies to continue treatment. These results suggest multi-faceted efforts at different levels, including social norms, may be needed to improve specialty palliative care integration for advanced cancer patients.