Levy Michael H, Cohen Seth D
Department of Medical Oncology, Fox Chase Cancer Center, Philadelphia, PA 19111, USA.
Semin Oncol. 2005 Apr;32(2):237-46. doi: 10.1053/j.seminoncol.2005.02.003.
There is a continuum of the goals of comfort and function in palliative care that begins with comfort and function being equal priorities and sedation being unacceptable. As disease progresses, the goals and preferences of the patient turn to coping with the loss of function caused by the disease and acceptance of unintentional sedation from the disease, its therapies, or symptom relief interventions. As patients approach the end of life, they may need intentional sedation for the relief of refractory symptoms. Such sedation can be divided into three categories: routine, infrequent, and extraordinary with respect to the frequency, difficulty, and risks involved with the drugs and routes of administration required to induce and maintain a level of sedation that relieves the patient's physical and existential symptoms. Extraordinary sedation with continuous infusions of midazolam, thiopental, and propofol can relieve refractory symptoms in most patients in their final days of life. Palliative care clinicians should become comfortable with the ethical justification and technical expertise needed to provide this essential, extraordinary care to the small but deserving number of patients in whom routine and infrequent sedation does not adequately relieve their suffering.
姑息治疗中舒适与功能的目标存在一个连续统一体，起初舒适和功能是同等重要的优先事项，镇静是不可接受的。随着疾病进展，患者的目标和偏好转向应对疾病导致的功能丧失，以及接受疾病、其治疗方法或症状缓解干预措施所带来的非故意镇静。当患者接近生命终点时，他们可能需要进行有意镇静以缓解难治性症状。这种镇静根据诱导和维持缓解患者身体及生存症状的镇静水平所需药物和给药途径的频率、难度及风险，可分为三类：常规、不频繁和特殊。通过持续输注咪达唑仑、硫喷妥钠和丙泊酚进行的特殊镇静可在大多数患者生命的最后几天缓解难治性症状。姑息治疗临床医生应熟悉为少数值得治疗但常规和不频繁镇静无法充分缓解其痛苦的患者提供这种必要的特殊护理所需的伦理依据和技术专长。
