Gristina Giuseppe R, Orsi Luciano, Carlucci Annalisa, Causarano Ignazio R, Formica Marco, Romanò Massimo
Recenti Prog Med. 2014 Jan;105(1):9-24. doi: 10.1701/1398.15554.
In Italy the birth rate decrease together with the continuous improvement of living conditions on one hand, and the health care progress on the other hand, led in recent years to an increasing number of patients with chronic mono- or multi-organ failures and in an extension of their life expectancy. However, the natural history of chronic failures has not changed and the inescapable disease's worsening at the end makes more rare remissions, increasing hospital admissions rate and length of stay. Thus, when the "end-stage" get close clinicians have to engage the patient and his relatives in an advance care planning aimed to share a decision making process regarding all future treatments and related ethical choices such as patient's best interests, rights, values, and priorities. A right approach to the chronic organ failures end-stage patients consists therefore of a careful balance between the new powers of intervention provided by the biotechnology and pharmacology (intensive care), both with the quality of remaining life supplied by physicians to these patients (proportionality and beneficence) and the effective resources rationing and allocation (distributive justice). However, uncertainty still marks the criteria used by doctors to assess prognosis of these patients in order to make decisions concerning intensive or palliative care. The integrated care pathway suggested in this position paper shared by nine Italian medical societies, has to be intended as a guide focused to identify end-stage patients and choosing for them the best care option between intensive treatments and palliative care.
在意大利，一方面出生率下降，另一方面生活条件持续改善以及医疗保健取得进步，近年来导致慢性单器官或多器官功能衰竭患者数量增加，且他们的预期寿命延长。然而，慢性功能衰竭的自然病程并未改变，疾病最终不可避免地恶化，缓解情况愈发罕见，住院率和住院时间不断增加。因此，当“终末期”临近时，临床医生必须让患者及其亲属参与预先护理计划，旨在就所有未来治疗以及相关伦理选择（如患者的最大利益、权利、价值观和优先事项）达成决策过程。因此，对慢性器官功能衰竭终末期患者的正确处理方法是在生物技术和药理学（重症监护）提供的新干预能力与医生给予这些患者的剩余生命质量（相称性和行善原则）以及有效的资源合理分配（分配正义）之间谨慎权衡。然而，医生用于评估这些患者预后以做出关于重症治疗或姑息治疗决策的标准仍然存在不确定性。这份由九个意大利医学协会共同发布的立场文件中建议的综合护理路径，应被视为一份指南，重点在于识别终末期患者，并为他们在强化治疗和姑息治疗之间选择最佳护理方案。
