2007年至2013年间持续深度镇静直至死亡的趋势：一项全国性重复调查。
Trends in Continuous Deep Sedation until Death between 2007 and 2013: A Repeated Nationwide Survey.
作者信息
Robijn Lenzo, Cohen Joachim, Rietjens Judith, Deliens Luc, Chambaere Kenneth
机构信息
End-of-life Care Research Group, Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium.
Department of Medical Oncology, Ghent University Hospital, Ghent, Belgium.
出版信息
PLoS One. 2016 Jun 23;11(6):e0158188. doi: 10.1371/journal.pone.0158188. eCollection 2016.
BACKGROUND
Continuous deep sedation until death is a highly debated medical practice, particularly regarding its potential to hasten death and its proper use in end-of-life care. A thorough analysis of important trends in this practice is needed to identify potentially problematic developments. This study aims to examine trends in the prevalence and practice characteristics of continuous deep sedation until death in Flanders, Belgium between 2007 and 2013, and to study variation on physicians' degree of palliative training.
METHODS
Population-based death certificate study in 2007 and 2013 in Flanders, Belgium. Reporting physicians received questionnaires about medical practices preceding the patient's death. Patient characteristics, clinical characteristics (drugs used, duration, artificial nutrition/hydration, intention and consent), and palliative care training of attending physician were recorded. We posed the following question regarding continuous deep sedation: 'Was the patient continuously and deeply sedated or kept in a coma until death by the use of one or more drugs'.
RESULTS
After the initial rise of continuous deep sedation to 14.5% in 2007 (95%CI 13.1%-15.9%), its use decreased to 12.0% in 2013 (95%CI 10.9%-13.2%). Compared with 2007, in 2013 opioids were less often used as sole drug and the decision to use continuous deep sedation was more often preceded by patient request. Compared to non-experts, palliative care experts more often used benzodiazepines and less often opioids, withheld artificial nutrition/hydration more often and performed sedation more often after a request from or with the consent of the patient or family.
CONCLUSION
Worldwide, this study is the first to show a decrease in the prevalence of continuous deep sedation. Despite positive changes in performance and decision-making towards more compliance with due care requirements, there is still room for improvement in the use of recommended drugs and in the involvement of patients and relatives in the decision-making process.
背景
持续深度镇静直至死亡是一种备受争议的医疗行为，尤其是在其加速死亡的可能性以及在临终关怀中的合理使用方面。需要对这种行为的重要趋势进行全面分析，以识别潜在的问题发展。本研究旨在调查2007年至2013年期间比利时弗拉芒地区持续深度镇静直至死亡的患病率及实践特征趋势，并研究医生姑息治疗培训程度的差异。
方法
2007年和2013年在比利时弗拉芒地区进行基于人群的死亡证明研究。报告医生收到关于患者死亡前医疗行为的问卷。记录患者特征、临床特征（使用的药物、持续时间、人工营养/补液、意图和同意情况）以及主治医生的姑息治疗培训情况。我们针对持续深度镇静提出了以下问题：“患者是否通过使用一种或多种药物持续深度镇静或保持昏迷直至死亡”。
结果
持续深度镇静在2007年首次上升至14.5%（95%置信区间13.1%-15.9%）后，2013年其使用率降至12.0%（95%置信区间10.9%-13.2%）。与2007年相比，2013年阿片类药物作为单一药物使用的频率降低，使用持续深度镇静的决定更多地是在患者要求之后做出。与非专家相比，姑息治疗专家更常使用苯二氮䓬类药物，较少使用阿片类药物，更常停止人工营养/补液，并且更常在患者或家属要求或同意后进行镇静。
结论
在全球范围内，本研究首次表明持续深度镇静的患病率有所下降。尽管在行为和决策方面朝着更符合适当护理要求有了积极变化，但在推荐药物的使用以及患者和亲属参与决策过程方面仍有改进空间。
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