Quill Timothy E, Lo Bernard, Brock Dan W, Meisel Alan
Center for Ethics, Humanities and Palliative Care, University of Rochester Medical Center, Rochester, New York 14642, USA.
Ann Intern Med. 2009 Sep 15;151(6):421-4. doi: 10.7326/0003-4819-151-6-200909150-00007.
Despite receiving state-of-the-art palliative care, some patients still experience severe suffering toward the end of life. Palliative sedation is a potential way to respond to such suffering, but access is uneven and unpredictable, in part because of confusion about different kinds of sedation. Proportionate palliative sedation (PPS) uses the minimum amount of sedation necessary to relieve refractory physical symptoms at the very end of life. To relieve suffering may require progressive increases in sedation, sometimes to the point of unconsciousness, but consciousness is maintained if possible. Palliative sedation with the intended end point of unconsciousness (PSU) is a more controversial practice that may be considered for much fewer refractory cases. There is more ethical consensus about PPS than PSU. In this article, the authors explore the clinical, ethical, and legal issues associated with these practices. They recommend that palliative care and hospice programs develop clear policies about PPS and PSU, including mechanisms for training and ensuring competency for clinicians, and approaching situations where individuals or institutions may conscientiously object.
尽管接受了最先进的姑息治疗，但一些患者在生命末期仍会遭受严重痛苦。姑息性镇静是应对此类痛苦的一种潜在方式，但获取途径不均衡且不可预测，部分原因是对不同类型的镇静存在混淆。适度姑息性镇静（PPS）在生命的最后阶段使用缓解难治性身体症状所需的最低剂量镇静剂。为了缓解痛苦可能需要逐渐增加镇静剂量，有时会达到昏迷状态，但如果可能的话会保持意识。以昏迷为预期终点的姑息性镇静（PSU）是一种更具争议性的做法，可能仅适用于极少数难治性病例。与PSU相比，关于PPS的伦理共识更多。在本文中，作者探讨了与这些做法相关的临床、伦理和法律问题。他们建议姑息治疗和临终关怀项目制定关于PPS和PSU的明确政策，包括培训机制和确保临床医生具备能力的机制，以及处理个人或机构可能出于良心拒斥的情况。
