Reid Thomas T, Demme Richard A, Quill Timothy E
University of California, 533 Parnassus Avenue, Box 0903, Suite U154, San Francisco, CA 94143-0903, USA.
Pain Manag. 2011 Jan;1(1):31-40. doi: 10.2217/pmt.10.1.
Despite state-of-the-art palliative care, some patients will require proportionate palliative sedation as a last-resort option to relieve intolerable suffering at the end of life. In this practice, progressively increasing amounts of sedation are provided until the target suffering is sufficiently relieved. Uncertainty and debate arise when this practice approaches palliative sedation to unconsciousness (PSU), especially when unconsciousness is specifically intended or when the target symptoms are more existential than physical.
We constructed a case series designed to highlight some of the common approaches and challenges associated with PSU and the more aggressive end of the spectrum of proportionate palliative sedation as retrospectively identified by palliative care consultants over the past 5 years from a busy inpatient palliative care service at a tertiary medical center in Rochester (NY, USA).
Ten cases were identified as challenging by the palliative care attendings, of which four were selected for presentation for illustrative purposes because they touched on central issues including loss of capacity, the role of existential suffering, the complexity of clinical intention, the role of an institutional policy and use of anesthetics as sedative agents. Two other cases were selected focusing on responses to two special situations: a request for PSU that was rejected; and anticipatory planning for total sedation in the future.
Although relatively rare, PSU and more aggressive end-of-the-spectrum proportionate palliative sedation represent responses to some of the most challenging cases faced by palliative care clinicians. These complex cases clearly require open communication and collaboration among caregivers, patients and family. Knowing how to identify these circumstances, and how to approach these interventions of last resort are critical skills for practitioners who take care of patients at the end of life.
尽管有先进的姑息治疗，但一些患者仍需要适度的姑息性镇静作为缓解临终时难以忍受的痛苦的最后手段。在这种做法中，会逐渐增加镇静剂量，直到目标痛苦得到充分缓解。当这种做法接近姑息性镇静至无意识状态（PSU）时，尤其是当特意导致无意识状态或目标症状更多是关于生存意义而非身体方面时，就会出现不确定性和争议。
我们构建了一个病例系列，旨在突出一些与PSU以及姑息性镇静范围中更激进的末期相关的常见方法和挑战，这些是由姑息治疗顾问在过去5年中从美国纽约罗切斯特一家繁忙的住院姑息治疗服务机构回顾性确定的。
姑息治疗主治医师将10个病例确定为具有挑战性，其中4个病例被选出来用于展示，因为它们涉及核心问题，包括行为能力丧失、生存意义痛苦的作用、临床意图的复杂性、机构政策的作用以及使用麻醉剂作为镇静剂。另外两个病例被选出来重点关注对两种特殊情况的应对：一个被拒绝的PSU请求；以及对未来完全镇静的预先规划。
尽管相对罕见，但PSU和姑息性镇静范围中更激进的末期代表了对姑息治疗临床医生所面临的一些最具挑战性病例的应对。这些复杂病例显然需要护理人员、患者和家属之间进行开放的沟通与协作。了解如何识别这些情况以及如何进行这些最后的干预措施，对于照顾临终患者的从业者来说是至关重要的技能。
