Danis M, Federman D, Fins J J, Fox E, Kastenbaum B, Lanken P N, Long K, Lowenstein E, Lynn J, Rouse F, Tulsky J
National Institutes of Health, Bethesda, MD 20892-1156, USA.
Crit Care Med. 1999 Sep;27(9):2005-13. doi: 10.1097/00003246-199909000-00047.
To identify the goals and methods for medical education about end-of-life care in the intensive care unit (ICU).
A status report on palliative care, a summary report of recent research on palliative care education, articles in the medical literature on end-of-life care and critical care, and expert opinion were considered.
A working group, including specialists in critical care, palliative care, medical ethics, consumer advocacy, and communications, was convened at the "Medical Education for Care Near the End of Life National Consensus Conference." A modified nominal group process was used to develop a consensus.
In the ICU, life and death decisions are often made in a crisis mode or in the face of uncertainty, and may necessitate the withholding and withdrawal of life-supporting technologies. Because critical illness often diminishes the capacity of patients to make decisions, clinicians must often make decisions in conjunction with surrogates, rather than with patients. Discontinuity of care can threaten trusting relationships, and cultural diversity can have a particularly powerful impact on choices for care. In the face of these realities, it is possible and appropriate to give compassionate palliative care to dying patients and their families in the ICU.
Teaching care of the dying in the ICU should emphasize the following: a) the goals of care should guide the use of technology; b) understanding of prognostication and treatment withholding and withdrawal is essential; c) effective communication and trusting relationships are crucial to good care; d) cultural differences should be acknowledged and respected; and e) the delivery of excellent palliative care is appropriate and necessary when patients die in the ICU.
确定重症监护病房（ICU）临终关怀医学教育的目标和方法。
考虑了一份姑息治疗现状报告、一份关于姑息治疗教育的近期研究总结报告、医学文献中有关临终关怀和重症监护的文章以及专家意见。
在“临终关怀医学教育全国共识会议”上召集了一个工作组，成员包括重症监护、姑息治疗、医学伦理学、患者权益倡导及沟通方面的专家。采用改良的名义群体法达成共识。
在ICU中，生死决策通常在危机模式下或面对不确定性时做出，可能需要停止和撤除维持生命的技术。由于危重病往往会削弱患者的决策能力，临床医生通常必须与代理人而非患者共同做出决策。护理的不连续性可能会威胁到信任关系，文化多样性可能对护理选择产生特别重大的影响。面对这些现实情况，在ICU中为濒死患者及其家属提供富有同情心的姑息治疗是可行且恰当的。
在ICU中开展临终关怀教学应强调以下几点：a）护理目标应指导技术的使用；b）理解预后判断以及停止和撤除治疗至关重要；c）有效的沟通和信任关系对于优质护理至关重要；d）应承认并尊重文化差异；e）当患者在ICU死亡时，提供优质的姑息治疗是恰当且必要的。
