Smallwood Natasha, Ross Lauren, Taverner John, John Jenny, Baisch Andreas, Irving Louis, Philip Jennifer
a Department of Respiratory and Sleep Medicine , The Royal Melbourne Hospital , Parkville , Victoria Australia.
b Department of Medicine (Royal Melbourne Hospital) , University of Melbourne , Parkville , Victoria Australia.
COPD. 2018 Oct;15(5):503-511. doi: 10.1080/15412555.2018.1549210.
Severe chronic breathlessness in advanced chronic obstructive pulmonary disease (COPD) is undertreated and few patients access specialist palliative care in the years before death. This study aimed to determine if symptom palliation or a palliative approach were delivered during the final hospital admission in which death occurred. Retrospective medical record audits were completed at two Australian hospitals, with all patients who died from COPD over 12 years between 1 January 2004 and 31 December 2015 included. Of 343 patients included, 217 (63%) were male with median age 79 years (IQR 71.4-85.0). Median respiratory function: FEV 0.80L (42% predicted), FVC 2.02L (73% predicted) and DLco 9 (42% predicted). 164 (48%) used domiciliary oxygen. Sixty (18%) patients accessed specialist palliative care and 17 (5%) wrote an advance directive prior to the final admission. In the final admission, 252 (74%) patients had their goal of care changed to aim for comfort (palliation) and 99 (29%) were referred to specialist palliative care. Two hundred and eighty-six (83%) patients received opioids and 226 (66%) received benzodiazepines, within 1 or 2 days respectively after admission to palliate symptoms. Median starting and final opioid doses were 10 mg (IQR = 5-20) and 20 mg (IQR = 7-45) oral morphine equivalent/24 h. Hospital site and year of admission were significantly associated with palliative care provision. Respiratory and general physicians provided a palliative approach to the majority of COPD patients during their terminal admission, however, few patients were referred to specialist palliative care. Similarly, there were missed opportunities to offer symptom palliation and a palliative approach in the years before death.
晚期慢性阻塞性肺疾病（COPD）患者的严重慢性呼吸困难未得到充分治疗，很少有患者在死前几年能获得专科姑息治疗。本研究旨在确定在导致死亡的最后一次住院期间是否提供了症状缓解或姑息治疗方法。在澳大利亚的两家医院完成了回顾性病历审核，纳入了2004年1月1日至2015年12月31日期间12年内所有死于COPD的患者。在纳入的343例患者中，217例（63%）为男性，中位年龄79岁（四分位间距71.4 - 85.0）。中位呼吸功能：第一秒用力呼气容积（FEV）0.80L（预测值的42%），用力肺活量（FVC）2.02L（预测值的73%），一氧化碳弥散量（DLco）9（预测值的42%）。164例（48%）使用家庭氧疗。60例（18%）患者获得了专科姑息治疗，17例（5%）在最后一次住院前写下了预先指示。在最后一次住院期间，252例（74%）患者的治疗目标改为以舒适（缓解）为目的，99例（29%）被转介至专科姑息治疗。286例（83%）患者在入院后1天或2天内分别接受了阿片类药物和苯二氮䓬类药物以缓解症状。阿片类药物的起始和最终中位剂量分别为10mg（四分位间距 = 5 - 20）和20mg（四分位间距 = 7 - 45）口服吗啡当量/24小时。医院地点和入院年份与姑息治疗的提供显著相关。呼吸科和普通内科医生在大多数COPD患者临终住院期间提供了姑息治疗方法，然而，很少有患者被转介至专科姑息治疗。同样，在死前几年也存在提供症状缓解和姑息治疗方法的机会错失情况。
