中華心理衛生協會

Purpose: In Taiwan, terminal patients' advance directives are largely handled by family members. However, few studies have investigated family members' experiences. We treated family members' participation in patients' advance care planning as a kind of health behavior that prepares family members for future psychosocial stress, which they may encounter while caring for the patient in the terminal stages. We adopted the transtheoretical model as a framework. This model posits that health behavior change goes through 6 stages (precontemplation, contemplation, preparation, action, maintenance, and termination), which correspond to different stages of preparation in terms of motivation and cognition. The aim of this study was to investigate characteristics of terminal patients' family members' behavioral presentations at different stages of change while participating in patients' advance care planning in a home-based care setting. Methods: Using a case study approach, we conducted 10 one-on-one, semi-structured interviews with family members of terminal patients. Verbatim interview data were submitted to thematic analysis using a deductive approach focused on the 5 stages of health behavior change from the transtheoretical model in order to categorize each participant's preparedness for advance care planning discussions. Results: We identified the concrete characteristics of each stage of change while participating in discussions of advance care planning. We derived 4 key characteristics to distinguish the stages of change. (1) ＂Avoidant attitude＂ was the key characteristic of the precontemplation stage. (2) Levels of concreteness and elaboration in ＂reflection and expression of a personal viewpoint＂ differentiated between the contemplation, preparation, and action stages. (3) ＂Activeness in communication＂ distinguished the preparation stage from the action stage. (4) ＂Recurrence of reflection＂ distinguished the maintenance stage from the action stage. Conclusions: (1) Casting participation in patients' advance care planning discussions as a kind of health behavior prepares family members not only for patients' upcoming bio-psycho-social problems that correspond to the patient's dying process but also for their own issues of life and death. (2) The stages of change described by the transtheoretical model help to depict the behavior surrounding advance care planning in concrete terms, and to reveal the complexity of discussion behavior. (3) Family members in different stages of advance care planning discussion have a different cognitive and motivational basis for behavioral change, and can profit from different intervention strategies. (4) Cultural indications for coping with illness and the physician-patient relationship need to be borne in mind in future work on promoting family participation in advance care planning.