Danis M
Department of Clinical Bioethics, Warren G. Magnuson Clinical Center, National Institutes of Health, Bethesda, MD 20892-1156, USA.
New Horiz. 1998 Feb;6(1):110-8.
Current recommendations about the care of dying patients advise that healthcare professionals understand and respect the goals, priorities, needs, and suffering of each dying patient and have command of the skills and resources required to address these concerns. Studies of important features of terminal illness, current use and outcome of intensive care for the terminally ill, and interventions designed to improve the outcome of care for patients who die in ICUs are reviewed to examine discrepancies between recommendations and the reality of ICU care for dying patients. Evidence indicates that it is difficult to predict the time of death or determine patient preferences about treatment prior to death. The utilization of intensive care prior to death varies widely across the United States and is a function of available resources more than individual patient need or choice. The pattern of withdrawal of life-sustaining treatment also varies widely and does not seem to follow guidelines. Families of deceased patients report that care could be improved by increased attention to analgesia and communication. The largest interventional study, the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment (SUPPORT), which provided physicians with information about patient prognosis and preferences for care, did not alter outcomes of end-of-life care. Smaller but successful interventional studies have included examination of an alternative team that provides care tailored to the needs of dying patients, a service tailored to promote family contact with the dying patient, and proactive consultation to facilitate care planning and communication with families. Research suggests that clinicians should be cognizant of the difficulty of predicting death and anticipate the need to change the goals of care as therapeutic trials fail; anticipate and treat bothersome symptoms of dying patients; recognize that family support and contact between the dying patient and family facilitate decision-making and acceptance of death; and facilitate the coordination of care and the development of alternative care teams in order to optimize end-of-life care.
当前关于临终患者护理的建议指出，医疗保健专业人员应理解并尊重每位临终患者的目标、优先事项、需求和痛苦，并掌握解决这些问题所需的技能和资源。本文回顾了晚期疾病的重要特征、当前对晚期患者的重症监护使用情况及结果，以及旨在改善重症监护病房（ICU）临终患者护理结果的干预措施，以研究建议与ICU临终患者护理现实之间的差异。有证据表明，很难预测死亡时间或在患者死亡前确定其对治疗的偏好。在美国，死亡前重症监护的使用差异很大，这更多地取决于可用资源，而非个体患者的需求或选择。维持生命治疗的撤除模式也差异很大，似乎并未遵循相关指南。已故患者的家属表示，通过加强镇痛和沟通，护理可以得到改善。最大规模的干预性研究——了解预后和对治疗结果及风险的偏好研究（SUPPORT），为医生提供了患者预后和护理偏好的信息，但并未改变临终护理的结果。规模较小但成功的干预性研究包括考察一个为临终患者需求提供定制护理的替代团队、一项促进家属与临终患者联系的服务，以及为便利护理计划和与家属沟通而进行的主动咨询。研究表明，临床医生应认识到预测死亡的困难，并在治疗试验失败时预见到改变护理目标的必要性；预见并治疗临终患者令人困扰的症状；认识到家属支持以及临终患者与家属之间的联系有助于决策制定和对死亡的接受；并促进护理协调以及替代护理团队的发展，以优化临终护理。
