Hasselaar Jeroen G J, Reuzel Rob P B, van den Muijsenbergh Maria E T C, Koopmans Raymond T C M, Leget Carlo J W, Crul Ben J P, Vissers Kris C P
Department of Anesthesiology, Pain, and Palliative Medicine, Radboud University Nijmegen Medical Center, the Netherlands.
Arch Intern Med. 2008 Mar 10;168(5):537-43. doi: 10.1001/archinternmed.2007.130.
This article examines delicate issues in continuous deep sedation (CDS) from the perspectives of different types of physicians. The following sensitive issues involved in CDS were investigated: artificial hydration, sedation for nonphysical discomfort, the relationship between CDS and euthanasia, and patient involvement in decision making for CDS.
A structured retrospective questionnaire concerning the most recent case of CDS during the past 12 months was sent to a sample of medical specialists (n = 727), general practitioners (n = 626), and nursing home physicians (n = 111).
Response rates were 26.4% for medical specialists, 37.4% for general practitioners, and 59.5% for nursing home physicians. Indications for CDS differed among the types of physicians. General practitioners (25.0%) were most often confronted with a patient request for euthanasia before starting CDS compared with medical specialists (8.9%) and nursing home physicians (6.5%). A decision to forgo artificial hydration in CDS was more often made by nursing home physicians (91.3%) compared with medical specialists (53.7%) and general practitioners (51.2%). Shorter survival was found for patients sedated for nonphysical discomfort (vs other patients) by general practitioners. Among all patients, 74.5% were involved in decision making before the start of CDS.
The present study demonstrates notable differences in CDS practice among various types of physicians. To what extent this is related to different patient populations or to different expertise requires further investigation. The use of CDS for nonphysical discomfort calls for critical examination to avoid ambiguous practice.
本文从不同类型医生的角度审视了持续深度镇静（CDS）中的敏感问题。对CDS中涉及的以下敏感问题进行了调查：人工补液、针对非身体不适的镇静、CDS与安乐死之间的关系以及患者参与CDS决策。
向医学专家样本（n = 727）、全科医生样本（n = 626）和疗养院医生样本（n = 111）发送了一份关于过去12个月内最近一次CDS病例的结构化回顾性问卷。
医学专家的回复率为26.4%，全科医生为37.4%，疗养院医生为59.5%。不同类型医生的CDS适应症有所不同。与医学专家（8.9%）和疗养院医生（6.5%）相比，全科医生（25.0%）在开始CDS之前最常面临患者的安乐死请求。与医学专家（53.7%）和全科医生（51.2%）相比，疗养院医生（91.3%）更常做出在CDS中放弃人工补液的决定。全科医生为非身体不适而镇静的患者（与其他患者相比）生存期较短。在所有患者中，74.5%在CDS开始前参与了决策。
本研究表明不同类型医生在CDS实践中存在显著差异。这在多大程度上与不同的患者群体或不同的专业知识有关，需要进一步调查。将CDS用于非身体不适需要进行严格审查，以避免做法模糊不清。
