Abstract:

Objective To understand the barriers of surrogate decision-makers participating in the advanced care planning（ACP） for patients with advanced cancer，and to provide references for the construction and intervention of educational programs. Methods Under the guidance of ternary reciprocal determinism，qualitative research method was used to conduct semi-structured interviews with 12 surrogate decision makers of advanced cancer patients in 2 tertiary hospitals of Zhejiang Province，and the data was analyzed using targeted content analysis. Results Based on the theory，the influencing factors of participating in ACP of the surrogate decision-makers of patients with advanced cancer were summarized into 3 themes：individual level-dual restriction of subjective thought and objective ability（value restriction，cognitive understanding deviation，economic condition restriction，patient’s situation control），environment level-synergistic influence of medical environment and social environment（limited medical conditions，pressure from public moral opinion，insufficient policy guarantee，lack of family consensus），behavior level - interaction of external guidance and internal feedback（lack of guidance of medical staff，experience support of medical decision-making）. Conclusion Surrogate decision-makers of patients with advanced cancer face many pressures before participating in the ACP. Under the guidance of the theory of knowledge，belief and practice，medical staff can give them pre-established medical care knowledge to correct their cognitive bias. Medical staff can guide the realization of “family-centered” decision-making mode to strengthen the family support of surrogate decision-makers. Medical staff also can lead the establishment of a surrogate decision-makers support group to share decision-making experience and provide medical decision-making assistance.

Key words: Advanced Cancer, Advanced Care Planning, Caregiver, Ternary Reciprocal Determinism, Palliative Care

摘要： 目的 剖析晚期癌症患者主要照顾者参与预立医疗照护计划的障碍，为预立医疗照护教育方案的构建提供参考依据。方法 在三元交互决定论指导下，应用质性研究方法，通过目的抽样，选取2023年2月16日—4月1日在浙江省2所三级甲等医院住院的12名晚期癌症患者的主要照顾者进行半结构式访谈，采用定向内容分析法分析访谈资料。结果 将晚期癌症患者主要照顾者参与预立医疗照护计划的障碍归纳为3个主题、10个亚主题。①个体层面：主观理念与客观条件双重制约，包括生死观和亲情观牵制、认知理解偏差、家庭经济条件制约、受患者的身心状况左右。②环境层面：医疗环境与社会环境协同影响，包括医疗条件受限、道德舆论施压、制度保障不足、家庭共识缺乏。③行为层面：外部引导与内部反馈共同作用，包括医护人员宣讲不足、决策经验不足。结论 晚期癌症患者的主要照顾者在参与预立医疗照护计划时面临诸多障碍。建议医护人员加强预立医疗照护及疾病知识宣讲，纠正主要照顾者的认知偏差，引导其采用“以家庭为中心”的决策模式，强化家庭支持；建立同伴支持小组，共享决策经验，提供医疗决策辅助。

关键词: 晚期癌症, 预立医疗照护计划, 照顾者, 三元交互决定论, 安宁疗护