van der Riet Pamela, Higgins Isabel, Good Phillip, Sneesby Ludmilla
School of Nursing and Midwifery, University of Newcastle, Callaghan Campus, Callaghan NSW, Australia.
J Clin Nurs. 2009 Jul;18(14):2104-11. doi: 10.1111/j.1365-2702.2008.02760.x.
The following discussion builds upon a previous publication that reported on the perceptions and discourses of palliative care nurses and doctors in relation to nutrition and hydration at the end of life. The aim of this paper is to report the discourses of nurses and doctors in relation to the challenges they faced when managing the care of patients with severe brain injury vs. the clearer cut situations when caring for terminally ill patients with cancer. The objectives of the study were to: explore the tensions in the discourses during end of life care, explore the challenges regarding nutrition and hydration at the end of life.
The decision to withdraw life support seems to be made more readily than the decision to withdraw nutrition and hydration at the end of life. The abatement of nutrition and hydration during the terminal phase of life is a controversial issue for a range reasons. Indeed, whilst it is accepted practice in the palliative care setting, nurses and doctors often struggle with the idea.
The design for this study used discourse analysis framed by a post structural framework.
Focus groups were conducted with nurses working in palliative care units. Single interviews were conducted with doctors from a tertiary palliative care unit.
The findings revealed contesting discourses involving quality of life and the prolongation of life.
The provision of food and fluid has profound emotional and social meanings for patients and families. The study reported here examined these issues with health professionals. The findings point to the challenges and tensions faced by health professionals in relation to decision making and medical hydration during end of life care. The concern is that tensions arise when decisions need to be made and how best to make these. The contesting discourses for nurses and doctors when nutrition and hydration is ceased involve maintaining quality of life vs. the prolongation of life.
Medical and nursing staff have different attitudes and beliefs towards end of life care. Tensions arise when decisions need to be made based on quality of life or prolongation of life. The successful merging of curative and palliative care is not without challenges. There has been little exploration of this situation.
以下讨论基于之前的一篇出版物展开，该出版物报道了姑息治疗护士和医生在临终时对营养与水合作用的看法及论述。本文旨在报告护士和医生在管理重度脑损伤患者护理工作时所面临的挑战的论述，以及与护理晚期癌症绝症患者时更明确的情况进行对比。本研究的目标是：探究临终护理期间论述中的紧张关系，探究临终时营养与水合作用方面的挑战。
在临终时，停止维持生命支持的决定似乎比停止营养与水合作用的决定更容易做出。由于多种原因，在生命终末期减少营养与水合作用是一个有争议的问题。的确，虽然这在姑息治疗环境中是被接受的做法，但护士和医生往往在这个想法上挣扎。
本研究的设计采用了后结构框架构建的话语分析方法。
对姑息治疗病房工作的护士进行焦点小组访谈。对三级姑息治疗病房的医生进行单独访谈。
研究结果揭示了涉及生活质量和延长生命的相互矛盾的论述。
提供食物和液体对患者及其家人具有深远的情感和社会意义。本文所报告的研究与卫生专业人员一起审视了这些问题。研究结果指出了卫生专业人员在临终护理期间决策和医疗水合作用方面面临的挑战和紧张关系。令人担忧的是，在需要做出决策时会出现紧张关系，以及如何最好地做出这些决策。当停止营养与水合作用时，护士和医生相互矛盾的论述涉及维持生活质量与延长生命。
医护人员对临终护理有不同的态度和信念。当基于生活质量或延长生命做出决策时会出现紧张关系。将治愈性护理和姑息性护理成功融合并非没有挑战。对此情况的探索很少。
