Reinke Lynn F, Meier Diane E
1 Department of Veterans Affairs, Puget Sound Health Care System , Health Services R&D, Seattle, Washington.
2 Department of Biobehavioral Nursing and Health Informatics, School of Nursing, University of Washington , Seattle, Washington.
J Palliat Med. 2017 Aug;20(8):813-820. doi: 10.1089/jpm.2017.0303.
Palliative care demonstrably improves quality of life for the seriously ill in a manner that averts preventable health crises and their associated costs. Because of these outcomes, palliative care is now broadening its reach beyond hospitals, and hospice care for those near death, to patients and their families living in the community with chronic multimorbidities that have uncertain or long expected survival. In this article, we address research needed to enable policies supportive of palliative care access and quality, including changes in regulatory, accreditation, financing, and training approaches in the purview of policy makers. Mr. K. is an 86-year-old male with multimorbidities, including severe chronic obstructive pulmonary disease, congestive heart failure, peripheral vascular disease, and atrial fibrillation requiring anticoagulation therapy. He fell in his mobile home and was unable to reach the telephone to call for help. Six hours later, his neighbor found him lying on the bedroom floor in pain and confused, and called 911. On examination, he was found to have a cold blue foot complicated by a large hematoma. The vascular surgery service was consulted to evaluate Mr. K. for revascularization or amputation. Although Mr. K. had several risk factors complicating his candidacy for general anesthesia, the team thought the benefits of surgery would outweigh the risks. Mr. K's daughter agreed to surgery telling her father "the doctors know best." Mr. K. replied "I just want to be out of pain." Six months later, Mr. K. remains in a skilled nursing facility due to post-op complications, including pneumonia, worsened confusion, and the inability to recover to enough function to live safely at home. He now suffers from depression, cognitive deficits, and social isolation. His daughter has had to take on a second job because she is struggling to pay for his continued long-term care, which costs $6000 per month. Money she had saved for her own retirement and her daughter's college tuition is already gone. In retrospect, she realizes the surgical team did not discuss the possibility of his survival with chronic debility and long-term functional dependency, nor the fact that Medicare would not pay for the care he now requires.
姑息治疗显著提高了重症患者的生活质量，避免了可预防的健康危机及其相关成本。鉴于这些成果，姑息治疗的覆盖范围正在扩大，从医院和临终关怀机构（针对濒死患者），扩展到患有慢性多种疾病、生存预期不确定或较长的社区患者及其家庭。在本文中，我们探讨了制定支持姑息治疗可及性和质量的政策所需的研究，包括政策制定者职权范围内监管、认证、融资和培训方式的变革。K先生是一位86岁的男性，患有多种疾病，包括严重的慢性阻塞性肺疾病、充血性心力衰竭、外周血管疾病以及需要抗凝治疗的心房颤动。他在活动房屋中摔倒，无法够到电话求救。六小时后，他的邻居发现他痛苦且神志不清地躺在卧室地板上，便拨打了911。检查发现，他的一只脚冰冷发蓝，并发了一个大血肿。血管外科会诊评估K先生是否适合进行血管重建或截肢手术。尽管K先生有几个危险因素使他不太适合全身麻醉，但团队认为手术的益处将超过风险。K先生的女儿同意手术，并告诉她的父亲“医生最清楚”。K先生回答说“我只想不再疼痛”。六个月后，由于术后并发症，包括肺炎、意识混乱加剧以及无法恢复到足够的功能以便安全地在家中生活，K先生仍住在一家专业护理机构。他现在患有抑郁症、认知缺陷和社交孤立。他的女儿不得不找第二份工作，因为她难以支付他持续的长期护理费用，每月高达6000美元。她为自己退休和女儿大学学费存的钱已经花光。回顾过去，她意识到手术团队没有讨论他在慢性虚弱和长期功能依赖状态下生存的可能性，也没有提及医疗保险不会支付他目前所需护理费用这一事实。
