Truog Robert D, Campbell Margaret L, Curtis J Randall, Haas Curtis E, Luce John M, Rubenfeld Gordon D, Rushton Cynda Hylton, Kaufman David C
Harvard Medical School and Children's Hospital, Boston, MA, USA.
Crit Care Med. 2008 Mar;36(3):953-63. doi: 10.1097/CCM.0B013E3181659096.
These recommendations have been developed to improve the care of intensive care unit (ICU) patients during the dying process. The recommendations build on those published in 2003 and highlight recent developments in the field from a U.S. perspective. They do not use an evidence grading system because most of the recommendations are based on ethical and legal principles that are not derived from empirically based evidence.
Family-centered care, which emphasizes the importance of the social structure within which patients are embedded, has emerged as a comprehensive ideal for managing end-of-life care in the ICU. ICU clinicians should be competent in all aspects of this care, including the practical and ethical aspects of withdrawing different modalities of life-sustaining treatment and the use of sedatives, analgesics, and nonpharmacologic approaches to easing the suffering of the dying process. Several key ethical concepts play a foundational role in guiding end-of-life care, including the distinctions between withholding and withdrawing treatments, between actions of killing and allowing to die, and between consequences that are intended vs. those that are merely foreseen (the doctrine of double effect). Improved communication with the family has been shown to improve patient care and family outcomes. Other knowledge unique to end-of-life care includes principles for notifying families of a patient's death and compassionate approaches to discussing options for organ donation. End-of-life care continues even after the death of the patient, and ICUs should consider developing comprehensive bereavement programs to support both families and the needs of the clinical staff. Finally, a comprehensive agenda for improving end-of-life care in the ICU has been developed to guide research, quality improvement efforts, and educational curricula.
End-of-life care is emerging as a comprehensive area of expertise in the ICU and demands the same high level of knowledge and competence as all other areas of ICU practice.
制定这些建议是为了改善重症监护病房（ICU）患者在临终过程中的护理。这些建议以2003年发布的建议为基础，从美国视角突出了该领域的最新进展。它们未采用证据分级系统，因为大多数建议基于并非源自实证证据的伦理和法律原则。
以家庭为中心的护理强调患者所处社会结构的重要性，已成为管理ICU临终护理的全面理想模式。ICU临床医生应在这种护理的各个方面具备能力，包括撤除不同维持生命治疗方式的实际和伦理方面，以及使用镇静剂、镇痛药和非药物方法减轻临终过程中的痛苦。几个关键的伦理概念在指导临终护理中发挥着基础性作用，包括 withhold 和 withdraw 治疗之间的区别、杀人行为和听任死亡之间的区别，以及预期后果与仅仅预见的后果之间的区别（双重效应原则）。已证明改善与家属的沟通可改善患者护理和家属的结局。临终护理的其他独特知识包括通知家属患者死亡的原则以及以同情方式讨论器官捐赠选项。即使患者死亡后，临终护理仍在继续，ICU应考虑制定全面的哀伤辅导计划，以支持家属和临床工作人员的需求。最后，已制定了一份全面的议程，以改善ICU中的临终护理，以指导研究、质量改进工作和教育课程。
临终护理正在成为ICU中一个全面的专业领域，需要与ICU实践的所有其他领域相同的高水平知识和能力。
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