慢性病患者非正式预立医疗照护计划行动框架构建与启示

doi:10.3761/j.issn.1672-9234.2026.08.014

中华护理教育 ›› 2026, Vol. 23 ›› Issue (8): 992-998.doi: 10.3761/j.issn.1672-9234.2026.08.014

慢性病患者非正式预立医疗照护计划行动框架构建与启示

王心茹¹(), 绳宇²^,^*()

¹ 复旦大学附属肿瘤医院护理部上海市 200032
² 中国医学科学院北京协和医学院北京市 100144

收稿日期:2026-01-04 出版日期:2026-08-15 发布日期:2026-08-14
通讯作者: *绳宇，E-mail：shengyumm@126.com
作者简介:王心茹：女，博士，主管护师，E-mail：wxrpumc@qq.com
第一联系人：作者贡献声明
研究构思与设计、框架构建为王心茹、绳宇；论文撰写为王心茹；论文修改为绳宇。
基金资助:
教育部人文社会科学研究规划基金项目(23YJA630079)

Construction and implications of the action framework for informal advance care planning in patients with chronic diseases

WANG Xinru¹(), SHENG Yu²^,^*()

¹ Department of Nursing， Fudan University Shanghai Cancer Center， Shanghai 200032， China
² Chinese Academy of Medical Sciences & Peking Union Medical College， Beijing 100144， China

Received:2026-01-04 Online:2026-08-15 Published:2026-08-14
Contact: *SHENG Yu，E-mail：shengyumm@126.com
Supported by:
The Humanities and Social Sciences Foundation of the Ministry of Education（Planned Program）(23YJA630079)

摘要/Abstract

摘要：

基于理论分析法，以社会生态系统理论和加拿大预立医疗照护计划（advance care planning，ACP）国家框架作为理论支持来源，将慢性病患者及其家庭的非正式ACP临床实践与我国社会生态环境相契合，确定不同社会生态系统层次下非正式ACP行动框架的模块及核心要素组成，推动未来非正式ACP在我国临床的可持续性、系统性的实施应用。

关键词: 预立医疗照护计划, 社会生态系统理论, 行动框架, 理论框架

Abstract:

The study takes social-ecological theory and the Canadian advance care planning（ACP） national framework as theoretical support sources，aligns the informal ACP clinical practices of patients with chronic diseases and their families with the social ecological environment in China. The researchers determine the modules and core elements of the informal ACP clinical practice theoretical framework at different levels of social ecosystems，based on theoretical analysis methods. This framework is expected to promote the sustainable and systematic implementation of informal ACP in clinical practice in Chinese.

Key words: Advance Care Planning, Social-Ecological Theory, Action Framework, Theoretical Framework

王心茹, 绳宇. 慢性病患者非正式预立医疗照护计划行动框架构建与启示[J]. 中华护理教育, 2026, 23(8): 992-998.

WANG Xinru, SHENG Yu. Construction and implications of the action framework for informal advance care planning in patients with chronic diseases[J]. Chinese Journal of Nursing Education, 2026, 23(8): 992-998.

图/表 2

参考文献 32

[1]	World Health Organization. Global action plan for the preven-tion and control of noncommunicable diseases 2013-2020[EB/OL].(2013-11-14)[2026-06-05]. https://www.who.int/publica-tions/i/item/9789241506236#:-:text=The%20WHO%20Global%20NCD%20action%20plan%202013%20-,role%20of%20inter-national%20cooperation%20to%20support%20national%20efforts.
[2]	Abbasi K. How to model life’s trajectory from major diagnosis to death[J]. BMJ, 2024,384:q568.
[3]	卢鑫欣, 李志刚, 符隆文. 中国临终医疗自主决策权再审视[J]. 医学与哲学, 2026, 47(2):41-46.
	Lu XX, Li ZG, Fu LW. A re-examination of the issue of patients’ autonomy in end-of-life medical decision-making in China[J]. Med Philos, 2026, 47(2):41-46.
[4]	邓仁丽, 陈柳柳, 史宝欣, 等. 中国文化背景下预立医疗照护计划的研究进展[J]. 中华护理杂志, 2015, 50(9):1117-1121.
	Deng RL, Chen LL, Shi BX, et al. Advance care planning under the background of Chinese culture[J]. Chin J Nurs, 2015, 50(9):1117-1121.
[5]	Sudore RL, Lum HD, You JJ, et al. Defining advance care plan-ning for adults:a consensus definition from a multidisciplinary Delphi panel[J]. J Pain Symptom Manag, 2017, 53(5):821-832.e1. doi: 10.1016/j.jpainsymman.2016.12.331
[6]	Centers for Disease Control and Prevention. Give peace of mind:advance care planning[EB/OL].(2017-11-15)[2025-12-21]. http://medbox.iiab.me/modules/en-cdc/www.cdc.gov/aging/ad-van-cecareplanning/index.htm.
[7]	Boerner K, Moorman SM, Carr D, et al. Insufficient advance care planning? Correlates of planning without personal con-versations[J]. J Gerontol B Psychol Sci Soc Sci, 2021, 76(1):104-108. doi: 10.1093/geronb/gbaa076
[8]	陈龙, 任明辉. 生前预嘱制度的检视与完善[J]. 协和医学杂志, 2025, 16(2):523-528.
	Chen L, Ren MH. Review and perfection of living will system[J]. Med J Peking Union Med Coll Hosp, 2025, 16(2):523-528.
[9]	Bronfenbrenner U. The ecology of human development:expe-riments by nature and design[M]. Cambridge: Harvard Universi-ty Press,1979:349.
[10]	Jimenez G, Tan WS, Virk AK, et al. State of advance care planning research:a descriptive overview of systematic re-views[J]. Pall Supp Care, 2019, 17(2):234-244. doi: 10.1017/S1478951518000500
[11]	Simply Psychology. Bronfenbrenner’s ecological systems theory[EB/OL].(2025-05-06)[2025-12-21]. https://www.simplypsycho-logy.org/Bronfenbrenner.html.
[12]	Psycologyfacts. Ecological systems theory by Bronfenbrenner[EB/OL].(2022-02-03)[2025-12-21]. https://psycologyfacts.com/ecological-systems-theory/.
[13]	Canadian Hospice Palliative Care Association. Advance care planning in Canada:national framework[R]. 2012.
[14]	Government of Canada. Implementation guide to advance care planning in Canada:a case study of two health authorities[EB/OL].(2017-05-04)[2025-12-21]. https://www.canada.ca/en/health-canada/services/health-care-system/reports-publications/palliative-care/ implementation-guide-advance-care-planning-cana-da-case-study-two-health-authorities-2008.html.
[15]	王心茹, 朱信雨, 贾玉玲, 等. 文化因素对安宁疗护实践影响的质性研究[J]. 中华护理杂志, 2023, 58(13):1552-1558. doi: 10.3761/j.issn.0254-1769.2023.13.003
	Wang XR, Zhu XY, Jia YL, et al. A qualitative study on the specificity of cultural factors in palliative care practice[J]. Chin J Nurs, 2023, 58(13):1552-1558. doi: 10.3761/j.issn.0254-1769.2023.13.003
[16]	景军. 大渐弥留之痛与临终关怀之本[J]. 中央民族大学学报(哲学社会科学版), 2021, 48(3):121-129.
	Jing J. Sufferings in the dying process as the core of terminal care[J]. J Minzu Univ China Philos Soc Sci Ed, 2021, 48(3):121-129.
[17]	Australia Government & Australia Digital Health Agency. Fra-mework for action:how Australia will deliver the benefits of digitally enabled health and care[EB/OL].(2018-07)[2025-12-21]. https://www.digitalhealth.gov.au/sites/default/files/2020-11/Framework_for_Action.pdf#:-: text=This%20framework%20outlines%2044%20key%20activities%20prioritised%20for, the%20benefits%20of%20digitally%20enabled%20health%20and%20care.
[18]	肖雪玲, Reynolds NR, 王红红. 理论解构的概念分析及在护理研究中的应用进展[J]. 中华护理杂志, 2020, 55(10):1578-1583. doi: 10.3761/j.issn.0254-1769.2020.10.024
	Xiao XL, Reynolds NR, Wang HH. Introduction of theoretical substruction and analysis of its utilization[J]. Chin J Nurs, 2020, 55(10):1578-1583. doi: 10.3761/j.issn.0254-1769.2020.10.024
[19]	徐天梦, 岳鹏. 临终患者和家属关于临终问题互动的研究进展[J]. 中国护理管理, 2019, 19(4):618-622.
	Xu TM, Yue P. Progress in the end-of-life issue interaction between patients and their families[J]. Chin Nurs Manag, 2019, 19(4):618-622.
[20]	Joung H, Jones RA. Cancer patient-family caregiver mutuality:a concept analysis[J]. Eur J Oncol Nurs, 2025, 76:102891. doi: 10.1016/j.ejon.2025.102891
[21]	Abera EG, Himbaro SA, Gizaw HS. Barriers to and readiness for advance care planning:a systematic review and meta-analysis of quantitative and qualitative evidence[J]. BMC Palliat Care, 2025, 25(1):31. doi: 10.1186/s12904-025-01972-3
[22]	周如女, 罗玲, 周嫣, 等. 应用PDCA循环管理提高护理满意度的效果[J]. 解放军护理杂志, 2013, 30(11):48-51.
	Zhou RN, Luo L, Zhou Y, et al. Application effects of PDCA circulatory management on promotion of nursing care satisfaction for inpatients[J]. Nurs J Chin PLA, 2013, 30(11):48-51.
[23]	Shewhart WA. Statistical method from the viewpoint of quality control[M]. Washington,DC: Graduate School,USDA,1939:86-87.
[24]	Tylor EB. Primitive culture:researches into the development of mythology,philosophy,religion,art,and custom[M]. London: John Murray,1871:1.
[25]	Patient Safety & Risk Management Department/Quality & Sa-fety Division. HA Guidelines on advance care planning[EB/OL].(2022-06-10)[2025-12-21]. https://www.ha.org.hk/visitor/ha_visitor_index.aspContent_ID=252688& Lang=CHIGB&Dime-nsion=100&Parent_ID=200776&Ver=HTML.
[26]	Chen WL, Chung JOK, Lam KKW, et al. End-of-life communi-cation strategies for healthcare professionals:a scoping review[J]. Palliat Med, 2023, 37(1):61-74. doi: 10.1177/02692163221133670
[27]	Ho AHY, Lall P, Tan WS, et al. Sustainable implementation of advance care planning in Asia:an interpretive-systemic framework for national development[J]. Pall Supp Care, 2021, 19(1):82-92. doi: 10.1017/S1478951520000590
[28]	Blackwood DH, Walker D, Mythen MG, et al. Barriers to adva-nce care planning with patients as perceived by nurses and other healthcare professionals:a systematic review[J]. J Clin Nurs, 2019, 28(23/24):4276-4297. doi: 10.1111/jocn.v28.23-24
[29]	吴玉苗, 奉典旭, 徐东浩, 等. 中国安宁疗护服务政策演变与发展[J]. 医学与哲学, 2020, 41(14):23-27.
	Wu YM, Feng DX, Xu DH, et al. The evolution and develop-ment of hospice care policy in China[J]. Med Philos, 2020, 41(14):23-27.
[30]	韩小玉, 张猛. 中国传统生命哲学与临终关怀的几点思考[J]. 医学与哲学, 2019, 40(7):37-39.
	Han XY, Zhang M. Thoughts on traditional Chinese philoso-phy of life and hospice care[J]. Med Philos, 2019, 40(7):37-39.
[31]	朱明霞, 谢淑玲, 黎想, 等. 粤港澳大湾区华人居民死亡素养现状及当代生死教育初探[J]. 中国医学伦理学, 2024, 37(4):491-498.
	Zhu MX, Xie SL, Li X, et al. The current situation of death literacy among Chinese residents in the Guangdong-Hong-Kong-Macao Greater Bay Area and its preliminary exploration on contemporary life and death education[J]. Chin Med Ethics, 2024, 37(4):491-498.
[32]	吕婷婷. 青少年与年轻成人癌症患者预立医疗照护计划干预模式构建研究[D]. 长沙: 湖南中医药大学, 2023.
	Lü TT. Research on the construction of advance care planning intervention model for adolescent and young adult cancer patients[D]. Changsha: Hunan University of Chinese Medicine, 2023.

慢性病患者非正式预立医疗照护计划行动框架构建与启示

Construction and implications of the action framework for informal advance care planning in patients with chronic diseases

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