Schwartz Denise Baird, Barrocas Albert, Wesley John R, Kliger Gustavo, Pontes-Arruda Alessandro, Márquez Humberto Arenas, James Rosemarie Lembo, Monturo Cheryl, Lysen Lucinda K, DiTucci Angela
Providence Saint Joseph Medical Center, Burbank, California
Atlanta Medical Center, Atlanta, Georgia.
Nutr Clin Pract. 2014 Dec;29(6):829-40. doi: 10.1177/0884533614546890. Epub 2014 Oct 7.
Based on current scientific literature, gastrostomy tube (G-tube) placement or other long-term enteral access devices should be withheld in patients with advanced dementia or other near end-of-life conditions. In many instances healthcare providers are not optimally equipped to implement this recommendation at the bedside. Autonomy of the patient or surrogate decision maker should be respected, as should the patient's cultural, religious, social, and emotional value system. Clinical practice needs to address risks, burdens, benefits, and expected short-term and long-term outcomes in order to clarify practice changes. This paper recommends a change in clinical practice and care strategy based on the results of a thorough literature review and provides tools for healthcare clinicians, particularly in the hospital setting, including an algorithm for decision making and a checklist to use prior to the placement of G-tubes or other long-term enteral access devices. Integrating concepts of patient-centered care, shared decision making, health literacy, and the teach-back method of education enhances the desired outcome of ethical dilemma prevention. The goal is advance care planning and a timely consensus among health team members, family members, and significant others regarding end-of-life care for patients who do not have an advance directive and lack the capacity to advocate for themselves. Achieving this goal requires interdisciplinary collaboration and proactive planning within a supportive healthcare institution environment.
根据当前科学文献，对于患有晚期痴呆症或其他接近生命末期疾病的患者，应避免放置胃造口管（G管）或其他长期肠内通路装置。在许多情况下，医疗保健提供者在床边实施这一建议的能力并不理想。应尊重患者或替代决策者的自主权，以及患者的文化、宗教、社会和情感价值体系。临床实践需要考虑风险、负担、益处以及预期的短期和长期结果，以明确实践中的变化。本文基于全面的文献综述结果，建议改变临床实践和护理策略，并为医疗保健临床医生，尤其是医院环境中的医生，提供相关工具，包括一个决策算法和一份在放置G管或其他长期肠内通路装置之前使用的清单。整合以患者为中心的护理、共同决策、健康素养和教育反馈方法等概念，可提高预防伦理困境的预期效果。目标是进行预先护理规划，并在医疗团队成员、家庭成员和其他重要人员之间就没有预先指示且缺乏自我主张能力的患者的临终护理及时达成共识。要实现这一目标，需要在支持性的医疗保健机构环境中进行跨学科协作和积极规划。
