Albert Ross H
Hartford Hospital, Hartford, CT, USA.
Am Fam Physician. 2017 Mar 15;95(6):356-361.
Physicians should be proficient at managing symptoms as patients progress through the dying process. When possible, proactive regimens that prevent symptoms should be used, because it is generally easier to prevent than to treat an acute symptom. As swallowing function diminishes, medications are typically administered sublingually, transdermally, or via rectal suppository. Opiates are the medication of choice for the control of pain and dyspnea, which are common symptoms in the dying process. Delirium and agitation may be caused by reversible etiologies, which should be identified and treated when feasible. When medications are required, haloperidol and risperidone are effective options for delirium. Nausea and vomiting should be treated with medications targeting the etiology. Constipation may be caused by low oral intake or opiate use. Preventive regimens to avoid constipation should include a stimulant laxative with a stool softener. Oropharyngeal secretions may lead to noisy breathing, sometimes referred to as a death rattle, which is common at the end of life. Providing anticipatory guidance helps families and caregivers normalize this symptom. Anticholinergic medications can modestly help reduce these secretions. Effective symptom control in end-of-life care can allow patients to progress through the dying process in a safe, dignified, and comfortable manner.
随着患者走向临终阶段，医生应熟练掌握症状管理。如有可能，应采用预防症状的主动治疗方案，因为预防急性症状通常比治疗更容易。随着吞咽功能减退，药物通常通过舌下、经皮或直肠栓剂给药。阿片类药物是控制疼痛和呼吸困难的首选药物，这是临终过程中的常见症状。谵妄和躁动可能由可逆病因引起，可行时应予以识别和治疗。需要用药时，氟哌啶醇和利培酮是治疗谵妄的有效选择。恶心和呕吐应使用针对病因的药物治疗。便秘可能由口服摄入量低或使用阿片类药物引起。避免便秘的预防方案应包括刺激性泻药和大便软化剂。口咽分泌物可能导致呼吸声大，有时称为临终喉鸣，这在生命末期很常见。提供预期指导有助于家属和护理人员使这种症状正常化。抗胆碱能药物可适度帮助减少这些分泌物。临终关怀中有效的症状控制可使患者以安全、有尊严和舒适的方式度过临终阶段。
