姑息关怀服务模式对癌症晚期患者生命质量的影响研究

目的 评估姑息关怀服务对癌症晚期患者生命质量的影响并提出管理建议。方法 采用问卷调查的方式对H医院接受姑息关怀治疗和常规抗癌治疗的248名癌症晚期住院患者的生命质量进行调查。选取中国癌症患者生命质量量表对癌症晚期患者的生命质量进行评估,然后通过统计分析探讨不同治疗方式下患者生命质量的差异。结果 癌症晚期患者生命质量普遍较差(36.38±4.82),其中躯体症状得分最低,依次是精神心理和社会关系。接受姑息关怀后患者生命质量及各指标得分均有显著提高。治疗前生命质量更差、疼痛程度更高的姑息关怀组患者,其治疗后的生命质量评分与常规抗癌组患者相比无显著差异,疼痛程度更是低于常规抗癌组。两组治疗方式下患者生命质量治疗前后的差值对比(6.82±2.71 vs 2.53±2.95),姑息关怀组的改善效果更明显(t=11.908,P<0.05)。结论 姑息关怀治疗相对于常规抗癌治疗,对癌症晚期患者生命质量的改善效果更为显著,应加强对以价值为核心的姑息关怀服务模式的宣传和推广。     

晚期癌症患者姑息治疗中的治疗性护患关系

晚期肿瘤患者的症状可以用药物解决，但充分而细致的临床护理才是临终关怀的基础，也是减轻患者各种不适和痛苦的重要手段。有效护理有赖于护理人员对患者的了解，建立互相信任、开放、良好的护患关系，是有效护理的根本保证。对于姑息性治疗中的晚期癌症患者，治疗更多地是作为一种支持、安慰、关怀和照顾的手段，减轻其躯体和心理痛苦。基层医院和社区医院应承担主要的临终关怀工作。现结合临床实践，探讨在基层医疗单位中如何建立治疗性护患关系及其在晚期癌症患者姑息治疗中的作用，并报告如下。     

采用姑息治疗方法治疗晚期患者86例体会

目的：评价姑息治疗方法治疗疾病晚期患者的疗效。方法：对所收治的86例患者采用心理治疗、扶正培本治疗、个性化的“三阶梯”止痛治疗。结果：姑息治疗能改善疾病晚期患者的精神状态,使其变得乐观,树立了信心和家属一起积极配合治疗,极大地提高了其终末期的生存质量,减轻和延长了其无症状生存期,同时减轻了家属的经济压力和自行护理的负担,是患者及家属乐于接受和认可的一种治疗方法。结论：姑息治疗对于疾病晚期的患者是有效的,值得医疗机构推广。     

老年人的肿瘤治疗不宜“斩草除根”

手术和放化疗等主张对癌细胞“赶尽杀绝”的根治性治疗手段，对于绝大部分代谢功能降低，脏器功能减退和伴发疾病增多的老年肿瘤患者来说，并不恰当，温和的姑息治疗反而更稳妥。     

姑息治疗-抗癌,以柔克刚

<正>在激进的治疗与消极等待死亡之间,癌症患者还有其他选择吗?也许姑息治疗是个值得考虑的治疗方案。姑息治疗并非临终关怀,它能够提升抗肿瘤治疗的效果,延长患者的生命,提高患者的生存质量。姑息治疗的手段多种多样,从止痛,到放疗、化疗甚至最新的靶向治疗,都可以作为姑息治疗的方法。那么,究竟什么是姑息治疗?     

姑息关怀服务指南——症状治疗

姑息关怀不仅是缓解症状,更强调减轻躯体、精神心理、社会和宗教方面的痛苦,帮助病人在尽可能积极和有创造性地生活的同时,尽可能坦然地面对即将到来的死亡.在患者疾病过程和家属居丧期间,姑息关怀也提供平衡的支持系统来帮助家属应对.姑息关怀最好由一个多功能的团队来提供,包括病人和家属、医生、护士、社会工作者、义工等.在此,重点讨论终末期患者的症状治疗.     

被误解的姑息治疗

<正>世界卫生组织指出,"姑息治疗是癌症控制方面的一个必不可少的内容",它有这么重要么?美国《梅奥临床进展》杂志上刊登了希望大众了解姑息治疗的10个方面,让人知道它到底能够帮癌症患者多大的忙。什么是姑息治疗姑息治疗是一种专业的医疗护理,专注于发现和减轻严重疾病带给患者的疼痛和其他症状。不论在疾病的哪个阶段,目前的治疗方案是什么,姑息治疗的目的都是提升患者的生存质量,满足患者及其家属的需求。由于患者和病痛并非存在于真空中,所以姑息治疗应该是一种积极     

临床姑息治疗的成本-效果研究系统综述:基于国际临床随机对照研究证据

目的:对国际发表的临终患者姑息治疗的临床随机对照研究(randomized controlled trail,RCT)的成本-效果评估文献进行系统综述,为我国支付及临床决策提供姑息疗法成本和成本-效果研究依据。方法:纳入2000年至2015年间国际发表的姑息治疗和常规治疗的RCT研究文献,对姑息治疗临床产出、相关成本及成本-效果研究进行汇总。结果:最终有6项RCT研究纳入本次系统综述分析。结果显示与常规治疗相比,在临终阶段实施姑息治疗不仅可以使患者的临床症状控制平稳、生命质量提高、缓解抑郁情绪、照顾满意度提高,而且患者生存期不会缩短,甚至延长。对临床资源使用情况显示,姑息治疗更少采用激进治疗,因此带来医疗费用的大量节省。结论:对临终期患者实施姑息治疗具有非常好的成本-效果优势,我国积极推动姑息治疗将会带来巨大的临床收益,并提高医疗资源的使用效率。     

结直肠癌肝转移姑息性治疗的新进展

只有约30%的结直肠癌伴肝转移的患者能够接受同时切除肝脏转移病变的根治性治疗。由于原发肿瘤的病变程度以及患者合并症的存在,姑息性治疗是不可切除患者唯一的选择。在一些病例中姑息性治疗可以局部或是全身控制肿瘤,延长存活时间。由于技术的逐渐进步,新的姑息性治疗方法在临床试验中得到检测并随后进入临床实践。本文就多学科间进行结直肠癌肝转移姑息性治疗的决策制定进行分析和总结。     

姑息治疗在中国

<正>虽然我国的医院并没有专门的姑息治疗中心,但是在癌症的治疗中,姑息治疗也是不可或缺的一部分。我们有专门的姑息治疗团队吗?没有。所有不能根治肿瘤的治疗,都可以被归类为姑息治疗,包括减轻患者的症状(如疼痛)、给患者补充营养等等,这些都不可能与传统的治疗完全分割开。例如止痛,癌症患者出现疼痛后,应该怎么止痛,这些都是有明确规范的,肿瘤医生也会依照规范进行。又例如,肺癌患者在     

The TLC model of palliative care in the elderly: preliminary application in the assisted living setting

Substantial shortfalls in the quality of palliative care of the elderly can be attributed to 5 fundamental flaws in the way end-of-life care is currently delivered. First, palliative care is viewed as a terminal event rather than a longitudinal process, resulting in a reactive approach and unnecessary preterminal distress in elderly patients suffering from chronic, slowly progressive illnesses. Second, palliative care is defined in terms of a false dichotomy between symptomatic and disease-focused treatment, which distracts attention from the proper focus of healing illness. Third, the decision about whether the focus of care should be palliative is not negotiated among patients, family members, and providers. Fourth, patient autonomy in making treatment choices is accorded undue prominence relative to more salient patient choices, such as coming to terms with their place in the trajectory of chronic illness. Fifth, palliative care is a parallel system rather than an integrated primary care process. A new theoretical framework--the TLC model--addresses these flaws in the provision of palliative care for elderly persons. In this model, optimal palliative care is envisioned as timely and team oriented, longitudinal, collaborative and comprehensive. The model is informed by the chronic illness care, shared decision making, and comprehensive geriatric assessment research literature, as well as previous palliative care research. Preliminary results of an intervention for elderly assisted living residents based on the TLC model support its promise as a framework for optimizing palliative care of elders.     

Distribution of resources for rendering medical care to cancer patients in hospices

Creation of a system of palliative care in the Russian Federation is a pressing problem of public health, which at present is going through the first stage of development. According to WHO estimations, at least 75% cancer patients need palliative care. The system of medical care to cancer patients functioning in countries with well-developed economy (United Kingdom, USA, Canada, Australia) intends equal distribution of resources between radical treatment and palliative care (including analgesia) and reflects the actual requirements of patients. The scope of care should be extended from symptomatic treatment to comprehensive (medical, psychological, social, and spiritual) care of patients and their families.     

Palliative care in Japan: current status and a nationwide challenge to improve palliative care by the Cancer Control Act and the Outreach Palliative Care Trial of Integrated Regional Model (OPTIM) study

Palliative care is an essential part of integrated cancer treatment. To improve palliative care throughout Japan, a nationwide demonstration project, the Outreach Palliative Care Trial of Integrated Regional Model (OPTIM) study, is ongoing. This article reviews the current status and the problems of palliative care in Japan and introduces the OPTIM study. Although the number of palliative care services is increasing, empirical evidence shows the quality of life of cancer patients is still inadequate. The OPTIM study is an intervention trial targeting 4 areas across Japan. Primary end points are quality of care reported by patients as well as the bereaved family, number of patients who received specialized palliative care services, and place of death. The interventions are comprehensively designed to cover all areas identified by the national task force. The OPTIM study will contribute to improve patients' quality of life by proposing a regional palliative care model suitable for Japan.     

Institutional patterns of symptomatic medication in hospitalized patients with advanced cancer

Although standards for palliative treatment of cancer patients at end of life are available, their use is perceived to vary among institutions depending on the prevailing philosophy of care. In this retrospective study, we reviewed the treatment of dying cancer patients receiving intravenous morphine transferred from a cancer center to a palliative care hospital. We recorded the dose of morphine and the use of other palliative medications, including adjuvant analgesic drugs. Although morphine doses tended to decrease after the transfer, the use of palliative medications was similar in the two institutions.     

Delirium in palliative care patients: focus on pharmacotherapy

Patients receiving palliative care often possess multiple risk factors and predisposing conditions for delirium. The impact of delirium on patient care in this population may also be far-reaching: affecting not only quality of remaining life but the dying process experienced by patients, caregivers, and the medical team as well. As palliative care focuses on comfort and symptom management, the approach to assessment and subsequent treatment of delirium in palliative care patients may prove difficult for providers to navigate. This article summarizes the multifactorial nature, numerous predisposing medical risk factors, neuropsychiatric adverse effects of palliative medications, pharmacokinetic changes, and challenges complicating delirium assessment and provides a systematic framework for assessment. The benefits, risks, and patient-specific considerations for treatment selection are also discussed.     

Overcoming the tendency to lie to dying patients

A meaningful death can be fostered for a patient and his or her family with the aid of medical treatment, specifically through the alleviation of the patient's suffering and pain. To recognize the dying process is a part of the art of medicine. Compassionate care for dying patients includes a move from a curative model of care to a palliative model of care in defining the primary goal. Hospice volunteer training and practice is sufficient palliative care training to develop these skills. The time has come for incorporating palliative care into the curriculum of medical school.     

Palliativversorgung im Blickwinkel gesetzlicher und regulatorischer Vorgaben in Deutschland

In Germany, palliative care has developed rapidly since the establishment of the first palliative care unit in 1983. More improvements in patient-centered care are only possible if legal requirements as well as education of physicians, nurses, and other professionals involved in palliative care are adapted to current needs. This paper provides an overview of legal and regulatory requirements including a critical appreciation of their influence on palliative care in Germany. Only recently has medical education in palliative medicine been implemented as an integral part of medical studies at German universities. Starting in 2014, physicians applying for a license to practice medicine will have to provide a certificate of basic training in this field. The challenge in upcoming years will be the establishment and enhancement of comprehensive, standardized, and quality-controlled education at the universities. Only six universities have established chairs for palliative medicine, and it will be essential to not only establish more chairs but also to involve medical students in the development of the education. Only minimal requirements are specified for education of nurses in palliative care in the legislation. However, standardized and quality-controlled advanced training courses are available. This training is frequently requested as a prerequisite for nurses working in palliative care. Only limited education programs exist for other professional groups that are an important part of the palliative care team. In addition to the development of palliative care for inpatients with an increasing number of palliative care units, hospices, and first chairs of palliative medicine, different forms of ambulant palliative care services have been developed. Changes in the legislation have influenced the situation for home care enormously in the last 5?years, also making it more complex. With the Law for the Consolidation of the Competition in Compulsory Health Insurance ("Gesetz zur St?rkung des Wettbewerbs in der gesetzlichen Krankenversicherung"), a legal claim for palliative home care has been implemented in the fifth book of the social law in 2007. The ambitious goal of full coverage with comprehensive palliative home care has still not been achieved in most locations. However, after initial negotiation difficulties between palliative care providers and health insurance funds, an increasing number of contracts have been made. As a consequence-in addition to more than 240 palliative care units in Germany-more than one hundred palliative care teams have begun work in the field of specialized palliative home care. Legal regulations for the supply of opioids and other medications for the treatment of patients at home have been adapted recently, thus, facilitating fast and comprehensive medical treatment in emergency situations. Overall, the legislation has been adapted significantly, hence, contributing to improvements for patients requiring palliative care. It remains to be seen whether additional adjustments are required in the future.     

The ethics of palliative sedation as a therapy of last resort

Many patients nearing the end of life reach a point at which the goals of care change from an emphasis on prolonging life and optimizing function to maximizing the quality of remaining life, and palliative care becomes a priority. For some patients, however, even high-quality aggressive palliative care fails to provide relief. For patients suffering from severe pain, dyspnea, vomiting, or other symptoms that prove refractory to treatment, there is a consensus that palliative sedation is an appropriate intervention of last resort. In this report, the National Ethics Committee, Veterans Health Administration examines what is meant by palliative sedation, explores ethical concerns about the practice, reviews the emerging professional consensus regarding the use of palliative sedation for managing severe, refractory symptoms at the end of life, and offers specific recommendations for institutional policy.     

Palliative care provision for patients with chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is a major cause of disability, morbidity and mortality in old age. Patients with advanced stage COPD are most likely to be admitted three to four times per year with acute exacerbations of COPD (AECOPD) which are costly to manage. The adverse events of AECOPD are associated with poor quality of life, severe physical disability, loneliness, and depression and anxiety symptoms. Currently there is a lack of palliative care provision for patients with advanced stage COPD compared with cancer patients despite having poor prognosis, intolerable dyspnoea, lower levels of self efficacy, greater disability, poor quality of life and higher levels of anxiety and depression. These symptoms affect patients' quality of life and can be a source of concern for family and carers as most patients are likely to be housebound and may be in need of continuous support and care. Evidence of palliative care provision for cancer patients indicate that it improves quality of life and reduces health care costs. The reasons why COPD patients do not receive palliative care are complex. This partly may relate to prognostic accuracy of patients' survival which poses a challenge for healthcare professionals, including general practitioners for patients with advanced stage COPD, as they are less likely to engage in end-of-life care planning in contrast with terminal disease like cancer. Furthermore there is a lack of resources which constraints for the wider availability of the palliative care programmes in the health care system. Potential barriers may include unwillingness of patients to discuss advance care planning and end-of-life care with their general practitioners, lack of time, increased workload, and fear of uncertainty of the information to provide about the prognosis of the disease and also lack of appropriate tools to guide general practitioners when to refer patients for palliative care. COPD is a chronic incurable disease; those in an advanced stage of the disease pursuing intensive medical treatment may also benefit from the simultaneous holistic care approach of palliative care services, medical services and social services to improve quality of end of life care.