为无家可归者提供姑息治疗的途径：复杂的生活，复杂的护理。
Access to palliative care for homeless people: complex lives, complex care.
机构信息
Netherlands Institute for Health Services Research (Nivel), P.O. Box 1568, 3500, BN, Utrecht, The Netherlands.
Center for Consultation and Expertise, Gouda, The Netherlands.
出版信息
BMC Palliat Care. 2018 Oct 24;17(1):119. doi: 10.1186/s12904-018-0368-3.
BACKGROUND
People experiencing homelessness often encounter progressive incurable somatic diseases in combination with psychiatric and psychosocial problems, and many need palliative care at the end of their lives. Little is known about how palliative care for this group can be started in good time and provided optimally. The objective of this paper is to give insight into the extent people experiencing homelessness have access to good palliative care.
METHODS
Qualitative in-depth interviews were held to reconstruct the cases of 19 people experiencing homelessness in the Netherlands. Eight cases concerned persons being in the palliative phase (using the surprise question) and the other 11 cases concerned persons recently died after a period of ill health due to somatic illness. We used purposive sampling until data saturation was reached. The total number of interviews was 52. All interviews were transcribed verbatim and analysed inductively.
RESULTS
Three key themes were: 'late access', 'capricious trajectory' and 'complex care'. The first key theme refers to the often delayed start of palliative care, because of the difficulties in recognizing the need for palliative care, the ambivalence of people experiencing homelessness about accepting palliative care, and the lack of facilities with specific expertise in palliative care for them. The second key theme refers to the illness trajectory, which is often capricious because of the challenging behaviour of people experiencing homelessness, an unpredictable disease process and a system not being able to accommodate or meet their needs. The third key theme refers to the complexity of their care with regard to pain and symptom control, psychosocial and spiritual aspects, and the social network.
CONCLUSIONS
The care for in the palliative phase does not satisfy the core requirements of palliative care since there are bottlenecks regarding timely identification, the social network, and the assessment and management of physical symptoms and psychosocial and spiritual care needs. Education in palliative care of outreach professionals, training staff in shelters in the provision of palliative care, and building a network of palliative care specialists for people experiencing homelessness.
背景
无家可归者经常患有无法治愈的进行性躯体疾病，并伴有精神和心理社会问题，许多人在生命末期需要姑息治疗。对于如何及时开始为这一群体提供姑息治疗以及如何提供最佳姑息治疗，人们知之甚少。本文旨在深入了解无家可归者获得良好姑息治疗的程度。
方法
采用定性深入访谈法，对荷兰 19 名无家可归者的病例进行重建。8 例为处于姑息阶段（使用意外问题）的患者，11 例为因躯体疾病而健康状况恶化后近期死亡的患者。我们采用了目的性抽样，直到达到数据饱和。总共进行了 52 次访谈。所有访谈均逐字记录并进行了归纳分析。
结果
三个关键主题是：“晚期获得”、“反复无常的轨迹”和“复杂的护理”。第一个关键主题是指姑息治疗的开始往往延迟，原因是难以识别姑息治疗的需求、无家可归者对接受姑息治疗的矛盾心理，以及缺乏具有姑息治疗专业知识的设施。第二个关键主题是指疾病轨迹，由于无家可归者的挑战行为、不可预测的疾病进程以及系统无法适应或满足他们的需求，疾病轨迹往往反复无常。第三个关键主题是指他们在疼痛和症状控制、心理社会和精神方面以及社会网络方面的护理复杂性。
结论
姑息阶段的护理不能满足姑息治疗的核心要求，因为在及时识别、社会网络以及身体症状和心理社会及精神关怀需求的评估和管理方面存在瓶颈。需要对外展专业人员进行姑息治疗教育，培训收容所工作人员提供姑息治疗，并为无家可归者建立姑息治疗专家网络。
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