Kobewka Daniel, Ronksley Paul, McIsaac Dan, Mulpuru Sunita, Forster Alan
Department of Medicine (Kobewka, Mulpuru, Forster), Division of General Internal Medicine, The Ottawa Hospital, University of Ottawa; Ottawa Hospital Research Institute (Kobewka, McIsaac, Mulpuru, Forster), Ottawa, Ont.; Department of Community Health Sciences (Ronksley), University of Calgary, Calgary, Alta.; Department of Anesthesiology and Pain Medicine (McIsaac) - The Ottawa Hospital, University of Ottawa; Performance Measurement (Forster), The Ottawa Hospital, Ottawa, Ont.
CMAJ Open. 2017 Mar 9;5(1):E222-E228. doi: 10.9778/cmajo.20160123. eCollection 2017 Jan-Mar.
There is currently debate over the benefits and harms of physician-assisted death. One of the factors influencing this debate is concern about symptoms in the days before death. The objective of this study was to describe the frequency of symptoms before death and determine patient characteristics associated with these symptoms.
We reviewed the medical record of every patient who died at a multisite academic teaching hospital over a 3-month period. We determined the number of episodes of pain, dyspnea, agitation and nausea during the final 48 hours of life and assessed the patient and encounter characteristics associated with 2 or more episodes of symptoms.
A total of 480 patients died during the study period. Of these patients, 29.2% (140/480) had 2 or more symptoms in the final 48 hours of life. Higher Elixhauser comorbidity scores (relative risk [RR] 1.35, 95% confidence interval [CI] 1.23-1.49), having a family doctor (RR 2.33, 95% CI 1.02-5.38), being admitted to the medical oncology service (RR 1.51, 95% CI 1.11-2.05) and having a documented order for no resuscitation written early during the stay in hospital (RR 1.38, 95% CI 1.01-1.89) were independently associated with symptoms. Admission to intensive care was associated with fewer symptoms (RR 0.39, CI 95% 0.19-0.80).
Symptoms are common in the final 48 hours of life, particularly in patients with multimorbidity who want limitations on the aggressiveness of their care. An integrated palliative approach is needed for select at-risk patients.
目前关于医生协助死亡的利弊存在争议。影响这场辩论的因素之一是对死亡前几天症状的担忧。本研究的目的是描述死亡前症状的发生频率，并确定与这些症状相关的患者特征。
我们回顾了一家多地点学术教学医院在3个月期间死亡的每位患者的病历。我们确定了生命最后48小时内疼痛、呼吸困难、烦躁和恶心发作的次数，并评估了与2次或更多次症状发作相关的患者及诊疗特征。
在研究期间共有480名患者死亡。在这些患者中，29.2%（140/480）在生命的最后48小时内出现了2种或更多症状。较高的埃利克斯豪泽共病评分（相对风险[RR]1.35，95%置信区间[CI]1.23 - 1.49）、有家庭医生（RR 2.33，95% CI 1.02 - 5.38）、入住医学肿瘤科室（RR 1.51，95% CI 1.11 - 2.05）以及在住院早期有不进行心肺复苏的书面医嘱（RR 1.38，95% CI 1.01 - 1.89）与症状独立相关。入住重症监护病房与较少的症状相关（RR 0.39，95% CI 0.19 - 0.80）。
症状在生命的最后48小时很常见，尤其是在患有多种疾病且希望限制积极治疗的患者中。对于选定的高危患者需要采用综合姑息治疗方法。
