Plonk William M, Arnold Robert M
Division of General Medicine, Geriatrics, and Palliative Care, Department of Internal Medicine, University of Virginia Health System, Charlottesville, Virginia 22908, USA.
J Palliat Med. 2005 Oct;8(5):1042-54. doi: 10.1089/jpm.2005.8.1042.
The care of patients in their last weeks of life is a fundamental palliative care skill, but few evidence-based reviews have focused on this critical period.
A systematic review of published literature and expert opinion related to care in the last weeks of life.
The evidence base informing terminal care is largely descriptive, retrospective, or extrapolated. While home deaths and hospice use are increasing, medical care near death is becoming more aggressive and hospice lengths of stay remain short. Though the prediction of impending death remains imprecise, studies have identified several common terminal signs and symptoms. Decreased communication near death complicates the determination of patient wishes, and advanced directives prior to the terminal stage are recommended. Anorexia and cachexia are common in dying patients but there is no evidence that this process is painful or responsive to intervention. While there is general consensus that artificial nutrition is not beneficial in dying patients, the use of artificial hydration is controversial, especially in the setting of delirium. Breathlessness has been shown to benefit from oral and parenteral opioids but not anxiolytics. Accumulation of respiratory tract secretions (death rattle) is common and usually responds to antimuscarinics. Physical pain typically decreases toward death but its assessment in dying patients is difficult. Terminal delirium may occur in up to one-third of patients, may have a reversible cause, and may respond to antipsychotics or benzodiazepines. Palliative sedation is controversial but widely used, especially internationally. Caregiver stress and bereavement may benefit from improved communication and hospice involvement.
While the terminal care literature is characterized by varying quality, numerous knowledge gaps, and frequent inconsistencies, it supports several common clinical interventions. More research is needed to resolve controversies, define effective therapies, and improve the outcomes of dying patients.
对处于生命最后几周的患者进行照护是一项基本的姑息治疗技能，但很少有基于证据的综述关注这一关键时期。
对已发表的与生命最后几周照护相关的文献及专家意见进行系统综述。
为终末期照护提供依据的证据大多是描述性的、回顾性的或推断性的。虽然在家中死亡和使用临终关怀服务的情况在增加，但濒死时的医疗护理却变得更加激进，且临终关怀机构的住院时间仍然较短。尽管对即将死亡的预测仍然不准确，但研究已经确定了几种常见的终末期体征和症状。濒死时沟通减少使确定患者意愿变得复杂，建议在终末期之前制定预先医疗指示。厌食和恶病质在临终患者中很常见，但没有证据表明这一过程会带来痛苦或对干预有反应。虽然普遍认为人工营养对临终患者没有益处，但人工补液的使用存在争议，尤其是在谵妄的情况下。已证明口服和胃肠外使用阿片类药物可缓解呼吸困难，但使用抗焦虑药无效。呼吸道分泌物积聚（临终喉鸣）很常见，通常对抗胆碱能药物有反应。身体疼痛通常在临近死亡时减轻，但对临终患者进行评估很困难。多达三分之一的患者可能会发生终末期谵妄，可能有可逆转的病因，并且可能对抗精神病药物或苯二氮䓬类药物有反应。姑息性镇静存在争议，但广泛使用，尤其是在国际上。改善沟通和临终关怀机构的参与可能有助于减轻照顾者的压力和丧亲之痛。
虽然终末期照护文献的特点是质量参差不齐、存在众多知识空白且频繁出现不一致之处，但它支持几种常见的临床干预措施。需要更多研究来解决争议、确定有效的治疗方法并改善临终患者的结局。
