目的:及时发现和诊断痴呆有利于提供适当的,预期护理和预防急性情况。然而,启动诊断测试是一个复杂而动态的过程,需要全科医生(GP)平衡相互竞争的优先事项.以前确定的障碍,比如缺乏时间,知识,和资源,可能不能完全代表这一过程中涉及的挑战。因此,本研究旨在研究全科医生在启动痴呆诊断轨迹时的更多内隐考虑因素.
方法:使用半结构化访谈对14名荷兰全科医生进行了定性研究,这些医生是通过最大变异抽样有目的地选择的。多学科研究小组使用主题分析对访谈笔录进行了多轮归纳分析。
结果:全科医生开始痴呆症诊断轨迹的考虑可以总结为三个相互关联的主题:(1)“假定患者的意愿”,也就是说,在拒绝或没有诊断请求的情况下,面临着想要尊重患者自主权的困境,同时识别问题并感到采取行动的紧迫性;(2)“GP试图不伤害”,也就是说,在不想伤害患者和/或亲属与痴呆的负担标签和晚期诊断可能的负面后果之间取得平衡;和(3)时间,信任,和跨专业合作影响诊断工作的及时性,也就是说,可供咨询的时间,时间作为诊断因素,GP的诊断信心,和信任的医患关系。
结论:这项研究表明,关于患者自主性和不伤害原则的重要伦理困境存在于启动痴呆症诊断测试的实际GP障碍背后。时间,信任,发现跨专业合作有助于全科医生确定每个患者及其亲属的正确决定和时机。未来的研究可以探索明确涉及患者及其亲属参与这种平衡行为的诊断决策辅助工具的价值。
OBJECTIVE: Timely detection and diagnosis of dementia are beneficial for providing appropriate, anticipatory care and preventing acute situations. However, initiating diagnostic testing is a complex and dynamic process that requires general practitioners (GPs) to balance competing priorities. Previously identified barriers, such as a lack of time, knowledge, and resources, may not fully represent the challenges involved in this process. Therefore, this study aimed to examine GPs\' more implicit considerations on starting the diagnostic trajectory for dementia.
METHODS: A qualitative study was conducted using semi-structured interviews with 14 Dutch GPs who were purposively selected through maximum variation sampling. The interview transcripts were inductively analyzed in multiple rounds by a multidisciplinary research team using thematic analysis.
RESULTS: GPs\' considerations on starting the diagnostic trajectory for dementia can be summarized in three main themes that are interconnected: (1) \'the presumed patient\'s willingness\', that is, facing a dilemma of wanting to respect patient autonomy in cases of denial or an absence of a diagnostic request, while at the same time identifying a problem and feeling the urgency to act; (2) \'the GP\'s attempt not to harm\', that is, balancing between not wanting to harm the patient and/or relatives with the burdensome label of dementia and with the possible negative consequences of a late diagnosis; and (3) \'time, trust, and interprofessional collaboration influence timeliness of diagnostic work-up\', that is, time available for consultations, time as a diagnostic factor, GP\'s diagnostic confidence, and trustful physician-patient relationship.
CONCLUSIONS: This study revealed that important ethical dilemmas regarding patient autonomy and the principle of doing no harm lie behind practical GP barriers to initiating diagnostic testing for dementia. Time, trust, and interprofessional collaboration were found to facilitate GPs in determining the right decision and timing with each individual patient and their relatives. Future research could explore the value of diagnostic decision aids that explicitly involve patients and their relatives in this balancing act.