Department of Medicine, Division of Cardiology, New York Medical College/Westchester Medical Center, Valhalla, NY 10595, USA.
Cardiol Rev. 2013 Jan-Feb;21(1):9-15. doi: 10.1097/CRD.0b013e31826d23ea.
Heart failure presents its own unique challenges to the clinician who desires to make excellent and humane care near the end of life a tangible reality. Accurate prediction of mortality in the individual patient is complicated by both the frequent occurrence of sudden death, both with and without devices, and the frequently chronic course that is punctuated by recurrent and more prominent acute episodes. A significant literature demonstrates that healthcare providers continue to have difficulty communicating effectively with terminally ill patients and their caregivers regarding end-of-life care preferences, and it is clear from the prognostic uncertainty of advanced heart failure that this kind of communication, and discussions regarding palliative care, need to occur earlier rather than later. This article discusses various means of providing palliative care, and specific issues regarding device therapy, cardiopulmonary resuscitation, and palliative sedation, with concurrent discussion of the ethical ramifications and pitfalls of each. A recent scientific statement from the American Heart Association begins to address some of the methodological issues involved in the care of patients with advanced heart failure. Above all, clinicians who wish to provide the highest quality of care to the dying patient need to confront the existential reality of death in themselves, their loved ones, and their patients so as to best serve those remanded to their care.
心力衰竭给希望在生命末期提供优质和人道关怀的临床医生带来了独特的挑战。准确预测个体患者的死亡率很复杂，因为经常发生突然死亡，无论是有设备还是没有设备，而且经常是慢性病程，反复出现更明显的急性发作。大量文献表明，医疗保健提供者在与终末期患者及其护理人员就临终关怀偏好进行有效沟通方面仍然存在困难，从晚期心力衰竭的预后不确定性可以清楚地看出，这种沟通以及关于姑息治疗的讨论需要更早而不是更晚进行。本文讨论了提供姑息治疗的各种方法，以及与设备治疗、心肺复苏和姑息性镇静相关的具体问题，并同时讨论了每种方法的伦理含义和陷阱。美国心脏协会最近的一份科学声明开始解决晚期心力衰竭患者护理中涉及的一些方法学问题。最重要的是，希望为临终患者提供最高质量护理的临床医生需要面对自己、亲人以及患者的死亡现实，以便为那些被托付给他们照顾的人提供最好的服务。
