Abraham Adam, Kutner Jean S, Beaty Brenda
Division of General Internal Medicine, University of Colorado at Denver and Health Sciences Center, Denver, Colorado 80209, USA.
J Palliat Med. 2006 Jun;9(3):658-65. doi: 10.1089/jpm.2006.9.658.
Alleviation of suffering is a fundamental goal of medicine, especially at the end of life. Although physical distress is a component of suffering, other determinants likely play a role. This study attempted to elucidate these other components in an effort to understand the nature of suffering better.
Prospective cohort study conducted in the Population-based Palliative Care Research Network (PoPCRN) among English-speaking adults. Data were collected at hospice admission and at frequent intervals until death or discharge. This paper presents patient-reported data collected at the first available assessment after admission, using the Condensed Memorial Symptom Assessment Scale (MSAS; 0=not distressing, 4=very distressing), the McGill Quality of Life Questionnaire (MQOL; 0=worst QOL, 10=best QOL) and 2 suffering scales, overall suffering and suffering caused by physical symptoms (0=not suffering, 10=extreme suffering). The study population (n=48) is limited to those with physical symptoms less than "somewhat" distressing on the MSAS-PHYS. Respondents were divided into two groups: no-mild overall suffering (0-3) and moderate-severe overall suffering (4-10) and compared based on demographics, MQOL scores, MSAS-PSYCH scores and suffering caused by physical symptoms.
Mean age 70 years (range, 33-91), mean Karnofsky score 46, 46% married, 54% male, 71% cancer, 93% non-Hispanic white. Compared to patients reporting no-mild overall suffering, patients reporting moderate-severe overall suffering were more likely to have a diagnosis other than cancer (83% vs. 57%, p=0.05), be younger (65 vs. 75 years, p=0.02) and have lower scores on the MQOL-psychological subscale (6.4 vs. 8.0, p=0.02) and overall QOL scale (6.2 vs. 7.2, p=0.04). No significant differences were noted with respect to gender, marital status, MSAS-PSYCH, or MQOL existential and support subscales. Study patients reporting worse overall suffering also reported worse suffering caused by physical symptoms (6.3 vs. 2.1, p<0.0001). There was little association between the MSAS-PHYS score and either overall suffering (correlation coefficient=0.18, p=0.21) or suffering resulting from physical symptoms (correlation coefficient=0.22, p=0.13).
Patients reporting lack of distress resulting from physical symptoms did not necessarily indicate lack of suffering because of physical symptoms or lack of overall suffering. Factors other than physical symptom distress, such as diagnosis, age, and QOL appear to affect the perception of suffering. In order to better address suffering at the end of life, care must be taken to understand differences between physical symptom distress, suffering caused by physical symptoms and overall suffering.
减轻痛苦是医学的一个基本目标，尤其是在生命末期。虽然身体疼痛是痛苦的一个组成部分，但其他因素可能也起作用。本研究试图阐明这些其他因素，以便更好地理解痛苦的本质。
在基于人群的姑息治疗研究网络（PoPCRN）中对说英语的成年人进行前瞻性队列研究。在临终关怀入院时及之后定期收集数据，直至死亡或出院。本文呈现入院后首次可得评估时患者报告的数据，使用简明纪念症状评估量表（MSAS；0 = 无痛苦，4 = 非常痛苦）、麦吉尔生活质量问卷（MQOL；0 = 最差生活质量，10 = 最佳生活质量）以及两个痛苦量表，即总体痛苦量表和由身体症状引起的痛苦量表（0 = 无痛苦，10 = 极度痛苦）。研究人群（n = 48）限于那些在MSAS - PHYS量表上身体症状小于“有些”痛苦的患者。受访者分为两组：无 - 轻度总体痛苦（0 - 3）组和中度 - 重度总体痛苦（4 - 10）组，并根据人口统计学特征、MQOL评分、MSAS - PSYCH评分以及由身体症状引起的痛苦进行比较。
平均年龄70岁（范围33 - 91岁），平均卡诺夫斯基评分46分，46%已婚，54%为男性，71%患有癌症，93%为非西班牙裔白人。与报告无 - 轻度总体痛苦的患者相比，报告中度 - 重度总体痛苦的患者更可能患有非癌症诊断（83%对57%，p = 0.05），年龄更小（65岁对75岁，p = 0.02），并且在MQOL - 心理子量表上得分更低（6.4对8.0，p = 0.02）以及在总体生活质量量表上得分更低（6.2对7.2，p = 0.04）。在性别、婚姻状况、MSAS - PSYCH或MQOL存在和支持子量表方面未观察到显著差异。报告总体痛苦更严重的研究患者也报告由身体症状引起的痛苦更严重（6.3对2.1，p < 0.0001）。MSAS - PHYS评分与总体痛苦（相关系数 = 0.18，p = 0.21）或由身体症状导致的痛苦（相关系数 = 0.22，p = 0.13）之间几乎没有关联。
报告身体症状无痛苦的患者不一定表明不存在由身体症状引起的痛苦或总体痛苦。身体症状疼痛之外的因素，如诊断、年龄和生活质量，似乎会影响对痛苦的感知。为了在生命末期更好地应对痛苦，必须注意理解身体症状疼痛、由身体症状引起的痛苦和总体痛苦之间的差异。
