安宁疗护门诊的构建与应用效果

目的 建立安宁疗护门诊,满足更多终末期患者的需求。 方法 设置安宁疗护诊室,由护士出诊,对患者进行筛查、签订安宁疗护知情同意和意愿确认书、全面评估、建立档案、发起多学科会诊、制订照护方案、合理转介、定期随访、提供安宁疗护信息咨询。统计门诊工作量和成效。 结果 2020年10月安宁疗护门诊开诊,至2021年5月30日,门诊量为136例次,针对患者痛苦症状,出诊护士能独立解决108项,发起多学科会诊28次;开展“互联网+”居家照护59例次、收治入院52例、转介基层医院25例;随访388例次。患者的安宁疗护需求满足程度较高;患者综合服务满意度为99.5%,家属综合服务满意度为99.3%。 结论 安宁疗护门诊能够满足终末期患者的需求,体现公立医院的公益性,整合地区资源进行区域安宁疗护联动,促进安宁疗护分级诊疗的开展,加强安宁疗护专科护士培养,推动安宁疗护事业的进一步发展。     

Rehabilitation needs of an inpatient medical oncology unit

OBJECTIVE: To identify prospectively functional impairments and rehabilitation needs in an acute care medical oncology unit. DESIGN: Prospective cohort study. SETTING: Inpatient medical oncology unit at a Veterans Affairs hospital. PARTICIPANTS: Fifty-five patients admitted over a 6-month period. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: FIM instrument, functionally based physical examination, Rehabilitation Needs Assessment, and Recreational Needs Assessment. RESULTS: On admission, the mean FIM total score was 105 out of 126, the FIM motor score was 72 out of 91, and the FIM cognitive score was 34 out of 35. The functionally based physical examination did not generally correlate with scores obtained on the FIM. Forty-eight (87%) patients had rehabilitation needs on admission. Forty-six (84%) patients had rehabilitation needs on discharge. Rehabilitation Needs Assessment on admission showed deconditioning in 42 (76%) patients; mobility impairment in 32 (58%) patients; a significant decrease in range of motion in 23 (42%) patients; deficits in activities of daily living in 12 (22%) patients; a need for recreational therapy in 7 (13%) patients; potential for benefit from patient education in 30 (55%) patients; and a need for modalities, edema control, or wound care in fever than 5% of patients. The most commonly requested recreational activity was reading. CONCLUSIONS: Patients admitted to inpatient medical oncology units have many unmet, remediable rehabilitation needs that may not be recognized by nonrehabilitation physicians and other clinical staff. These findings suggest that assessment of medical oncology patients may be enhanced by consultation with rehabilitation medicine specialists.     

Demographic and clinical determinants of having do not resuscitate orders in the intensive care unit of a comprehensive cancer center

To understand the needs of patients and family members as physicians communicate their expectations about patients admitted to the intensive care unit (ICU), we evaluated the demographic and clinical determinants of having a Do Not Resuscitate (DNR) order for adults with cancer. Patients included were admitted from June 16, 2008-August 16, 2008, to the ICU in a comprehensive cancer center. We conducted a prospective chart review and collected data on patient demographics, length of stay, advance directives, clinical characteristics, and DNR orders. A total of 362 patients met the inclusion criteria; only 15.2% had DNR orders before ICU discharge. In the multivariate analysis, we found that medical admission was an independent predictor of having a DNR order during the ICU stay (odds ratio = 3.65; 95% confidence interval, 1.44-9.28); we also found a significant two-way interaction between race/ethnicity and type of admission (medical vs. surgical) with having a DNR order (p =?.04). Although medical admissions were associated with significantly more DNR orders than were surgical admissions, we observed that the subgroup of non-white patients admitted for medical reasons was significantly less likely to have DNR orders. This finding could reflect different preferences for aggressive care by race/ethnicity in patients with cancer, and deserves further investigation.     

Palliative care is a key component of daily practice in oncology: descriptive study of hospitalisation events at an oncology treatment centre

Purpose  

The impact that palliative care services have had on admission to oncology services has not been well-defined. This retrospective study was undertaken in the oncology service of a general hospital where there is also a palliative care service.     

Dying in hospital of terminal heart failure or severe dementia: the circumstances associated with death and the opinions of caregivers

BACKGROUND: Improving the care provided to elderly patients affected by end-stage chronic diseases dying in acute hospitals is a health priority. We evaluated the circumstances related to death in end-stage non-cancer patients dying in two acute care hospitals, and their caregiver's opinions about the death. METHODS: Some 102 patients, over 64 years of age, with end-stage dementia (37%) or congestive heart failure (64%), were included in the study. Caregiver's opinions on the circumstances of death were obtained using a questionnaire. In addition, we collected data regarding written instructions on several items, including do not resuscitate (DNR) orders, decisions about care in terms of the level or intensity of interventions, information provided to relatives about the prognosis, total withdrawal of normal drug therapy, and provision of palliative care. RESULTS: Caregivers stated that the clinical information was accurate in 67.6% of cases, and the control of symptoms was good in 55%. However, the perception of pain persisted in 14% and uncontrolled dyspnoea in 45%. The end-of-life care was assessed as: excellent 30.5%, good 36%, fairly good 25.5%, bad 6%, and very bad 2%. DNR orders were specified in 89% of patients, decisions concerning the intensity of care in 64%, and 80% of relatives were aware of the prognosis. Drug therapy was withdrawn in 64% of cases, and terminal palliative care was initiated in 79.5%. CONCLUSION: Our results suggest that some aspects of the palliative care provided to elderly patients with end-stage chronic diseases, admitted to acute care hospitals, could be improved. Such aspects include the clinical information provided and the successful control of specific symptoms.     

The impact of do-not-resuscitate order on triage decisions to a medical intensive care unit

Purpose

To determine whether the presence of a do-not-resuscitate (DNR) order impacts on triage decisions to a medical intensive care unit (MICU) of an academic medical center.

Methods

Data were collected on 179 patients in whom MICU consultation was sought and included demographic, clinical information, diagnoses, ICU admission decision, Acute Physiological and Chronic Health Evaluation II (APACHE II) score, and the presence of DNR order. Functional status was determined retrospectively using the Modified Rankin Score.

Results

The only factor that influenced MICU admission was the presence of DNR order at the time of MICU consultation (odds ratio, 0.25; 95% confidence interval, 0.09-0.71, P < .006). There was no difference between the age, APACHE II scores, or functional status between admitted or refused. Medical intensive care unit admission was associated with increased length of stay without difference in mortality.

Conclusion

The presence of a DNR order at the time of MICU consultation was significantly associated with the decision to refuse a patient to the MICU.     

A survey of the perspectives of specialist palliative care providers in the UK of inpatient respite

One of the major reasons for admission of patients to hospital in late stage disease is the inability of carers to continue to provide care at home. Specialist palliative care services have typically admitted patients for acute symptom control, terminal care and respite care to benefit them and their carers. This paper reports the results of a cross-sectional survey of inpatient respite care provision provided by specialist palliative care services and hospices in the UK. A structured questionnaire was mailed to 242 clinical services managers listed in the Hospice Information Directory in 2003. A 69% response rate was achieved. The questionnaire explored the nature of respite services, their purpose, organization, delivery and examined definitions used. The analysis indicated that 80% of the sample provided inpatient respite care. Most inpatient respite admissions were planned, of fixed duration (7-14 days) and were intended to benefit patients and carers. There was some evidence that respite provision was regarded as a lower priority than admissions for symptom control and terminal care, and that patients' needs were prioritized over those of carers. Only 10% of services conducted regular, routine audit, with very few seeking the views of service users. Findings suggest that carers' needs and wishes are not prioritized by specialist palliative care services offering inpatient respite, which may mean that they find it difficult to maintain their caregiving roles over longer disease trajectories or in the face of overwhelming demands.     

The ethics and practicalities of consent in palliative care research: an overview

In order to ensure that further developments and improvements are made in palliative care, research is essential. Palliative care is no different from other specialities in that it needs a scientific foundation on which to base its practice. Research in palliative care is particularly difficult, however, because of the population under study. Research in palliative care presents a 'minefield' of ethical issues. One of the major issues is how to obtain informed consent from patients. This article discusses the practical and ethical issues surrounding consent for quantitative research in palliative care, and offers some guidance to health professionals considering the issue with patients.     

European attitudes towards ethical problems in intensive care medicine: Results of an ethical questionnaire

A questionnaire was sent to the 590 members of the European Society of Intensive Care Medicine to define both the current practices and the opinions of these specialists on various ethical issues. The answers from 242 (41%) European members were collected and analysed. The first part of the questionnaire was designed to define the criteria for admission to Intensive Care throughout Europe. Admissions to the ICU were generally or commonly limited by the number of available beds according to 57% of the respondents and sometimes or almost never according to 41% (100/242). Bed availability in the ICU was especially limited in Spain, Portugal, Italy and the United Kingdom. Despite limited bed availability, two thirds of the respondents did admit patients who were thought to have little or no hope of survival other than for a few weeks. When asked about what ought to be done in these circumstances, the number of respondents who supported the admission of such terminal patients to ICU was halved. These data illustrate the heterogeneity of admission practices in Europe and stress the need for all ICUs to define a policy for admission. The second part was designed to assess the information given to patients in the ICU. Only 24 (10%) of the respondents stated that they always delivered complete information to their patients and only 31 (13%) thought they should do so. When an iatrogenic incident occurred, only 39 (16%) claimed to relate exactly what had happened, to the patient or their relatives but 121 (50%) thought they should. Informed consent was usually reuired for surgery or gastroscopy and the administration of a new was still not required by 49 (20%) participants but the majority favored more stringent requirements (i. e. written informed consent). Most participants reported that they would accept the decision of a competent patient who wished to refuse some surgical intervention. Thus it appears that most Intensive Care doctors do aspire to respect their patients' desires and some support the principle of informed consent. However, it seems that the critically ill patient is rarely fully informed about his condition. The third part was designed to assess current attitudes towards withholding and withdrawing life support. Orders not to resuscitate (DNR orders) were frequently used but were usually verbal. 31% discussed the DNR order with the patient whereas 57% discussed it with the family. Italy was the country in which DNR orders were the least frequently used. Withholding, withdrawing life support and euthanasia were a part of the practice of 83%, 63% and 36% of respondents, respectively. The majority supported the principle of limited care. Withdrawal of all support (including intravenous fluids and feeding) was usually preferred to euthanasia. This was especially true for doctors of the Catholic falth. The entire staff of the ICU was involved in the decision to withhold/withdraw treatment according to 52% of respondents whereas 45% limited participation to the medical staff. However, some of these doctors favored the involvement of the entire staff of the ICU with the patient and/or the family in the decision making process. Only 38% felt that an Ethics Consultant (or committee) would help in this process. On occasions when the family insisted on withholding or withdrawing life support, this had little influence on the decision whereas it had a stronger effect when insisting on full support.This study was sponsored by the European Society of Intensive Care Medicine     

CPR or DNR? End-of-life decision in Korean cancer patients: a single center’s experience

Purpose Whether or not physicians should conduct cardiopulmonary resuscitation (CPR) in terminal cancer patients has long been debated. We conducted this prospective observational study to characterize current CPR and do-not-resuscitate (DNR) practice among terminal cancer patients in South Korea.Materials and methods The study involved patients with terminal cancer who were admitted at the Seoul National University Boramae Hospital for supportive care only, and who died between January 1, 2003 and April 30, 2004. We investigated the practices relating to the DNR directive, i.e., how many days before death was the directive effective, and from whom was it obtained.Results Of the enrolled 165 patients, 97 were male with a mean age of 65. Median duration of admission to death was 24 days (range 7–207, mean 31.7). The DNR directive was implemented in 143 patients (86.7%). All discussions about DNR took place between physician and family members, except in only one case. DNR directives were enacted at a median of 8.0 days (range 0–79, mean 12.15) before death. For 18 patients, the DNR directive was formally taken on the day of admission. In contrast, 14 cases (9.8%) were agreed on the day of death, 18.8% within 48 h of death, and 46.8% (67 of 143) within 1 week before death, 62% before 10 days, and 71.3% within 2 weeks. The worse the performance status of the patient, the earlier the DNR discussion was issued. Also, the lower the economic and educational status of the family member, the earlier the DNR directive was attained. Of the 165 patients with terminal cancer, CPR was performed in 13 cases (7.9%): in seven cases (4.2%) CPR was requested by a family member, and in six cases arrest occurred before DNR discussion was issued. None of the resuscitated patients survived.Conclusion In relation to DNR decisions in South Korean cancer patients, proxy decision-making is overwhelming and issuance of DNR discussion is raised at a late stage.     

Informed consent: An Israeli bone marrow transplant unit's perspective

Israeli bone marrow transplant (BMT) patients are drawn from a heterogenous population of Israeli Jews, Israeli Arabs and patients from outside Israel. This presents difficulties in communicating the ethical dilemmas that surround the BMT procedure to the patients and their families. Among these dilemmas is the issue of informed consent. A pilot study was conducted to assess the current informed consent practices in an Israeli BMT Unit. The sample consisted of 13 Hebrew speaking patients. The purpose of the study was to evaluate BMT patients: (i) information seeking behaviour; (ii) preferences for participation in treatment decisions; and (iii) attitudes and behaviours towards the current informed consent document. The study found that patients did not read the informed consent form. Of the nine patients who read it, three considered it superfluous and seven signed it almost immediately after reading it. Surprisingly, the results also showed that, despite the greater degree of risk associated with BMT treatment, the information seeking behaviour scores of BMT patients were similar to those of cancer patients receiving oncology treatment on an ambulatory basis.     

Prospective validation of the palliative prognostic index in patients with cancer

The Palliative Prognostic Index (PPI) was devised and validated in patients with cancer in a hospice inpatient unit in Japan. The aim of this study was to test its accuracy in a different population, in a range of care settings and in those receiving palliative chemotherapy and radiotherapy. The information required to calculate the PPI was recorded for patients referred to a hospital-based consultancy palliative care service, a hospice home care service, and a hospice inpatient unit. One hundred ninety-four patients were included in the study, 43% of whom were receiving chemotherapy /or radiotherapy or both. Use of the PPI split patients into three subgroups based on PPI score. Group 1 corresponded to patients with PPI4 and 6, median survival five days (95% CI 3, 11). Using the PPI, survival of less than three weeks was predicted with a positive predictive value of 86% and negative predictive value of 76%. Survival of less than six weeks was predicted with a positive predictive value of 91% and negative predictive value of 64%. The PPI is quick and easy to use, and can be applied to patients with cancer, in hospital, in hospice, and at home. It may be used by general physicians to achieve prognostic accuracy comparable, if not superior, to that of physicians experienced in oncology and palliative care, and by oncology and palliative care specialists, to improve the accuracy of their survival predictions.     

Moral Justification of Phase 1 Oncology Trials

ABSTRACT

This article attempts to answer the following normative questions: Can one consider the design of Phase 1 trials ethically appropriate due to the unfavorable ratio of risks and benefits? What are some ethical safeguards for Phase 1 oncology research? A comparative review of literature contributed to the consolidation of the proposed ethical framework for Phase 1 oncology trials. This framework gives a special attention to issues of therapeutic misconception and vulnerability. The benefits and dangers associated with the enrollment in trials are described as well as the absence of alternatives, treatment-specific optimism, and vagueness in factual presentation during the informed consent process. The notion of therapeutic misconception is contrasted with optimism despite realism that stems from psychological, cultural, and religious factors and not necessarily from the lack of information. Close attention is given to the possible ways in which the inherent uncertainty and resulting cognitive biases may affect the informed consent process and the definition of therapeutic misconception. The article ends with recommendations for an ethical way of enrolling palliative patients in early stages of oncology research, giving special attention to provision of adequate consent, protection of vulnerability, and avoidance of therapeutic misconception.     

Survey of palliative care programs in United States teaching hospitals

In order to estimate the prevalence of palliative care programs in academic hospitals in the United States, we surveyed a random sample of 100 hospitals in the Council of Teaching Hospitals and Health Systems directory. Sixty percent of hospitals provided information. At least 26% of hospitals had either a palliative care consultation service or inpatient unit and 7% had both. Eighteen percent of hospitals had a palliative care consultation service alone, 19% had an inpatient palliative care unit, 22% reported a hospice affiliation, and 17% had a hospice inpatient contract. Additionally, at least 20% of the remaining hospitals were planning a palliative care program. The consultation services had an average daily census of 6; the inpatient units had an average of 12 beds. Palliative care consultation programs were largely affiliated with departments of medicine or hematology/oncology, and were typically staffed by a physician and a nurse. Only half had a dedicated social worker, one third had a chaplain, one third had a pharmacist, and a few included a bereavement coordinator or volunteer director, suggesting that the hospice model of interdisciplinary care is not being adopted regularly in palliative care programs. In comparison, almost half of hospitals noted established pain services. In conclusion, palliative care programs, although found in a minority of surveyed hospitals, are becoming an established feature of academic medical centers in the United States. More detailed information is needed about the type and quality of care they provide.     

Exploration of the decision-making process for inpatient hospice admissions

AIM: This paper discusses some of the findings of a qualitative study which described the decision-making processes that occurred during multidisciplinary meetings when prioritizing hospice inpatient admissions. BACKGROUND: Healthcare rationing and resource allocation have been identified as important but under-represented issues in the British nursing literature generally, and specifically within the field of palliative care. Little evidence currently exists about the rationing decisions made at a clinical level in hospices or palliative care units. METHOD: Adopting an ethnographic approach, data were collected at three hospice sites from three meetings at each site by observation, tape recording and transcribing of the meeting dialogue and examination of the available documentation from admissions meetings. The data were collected in 2002. RESULTS: Factors identified as potentially influential in these decisions included patient diagnosis, symptoms, current location and the stated reason for admission. The person who had assessed the patient's need for admission and whether or not a patient was personally known to a clinician present at the meeting also appeared important. The process seemed complex and incorporated different decision-making methods. Analysis of the group interactions suggested that these meetings were predominantly medically-led. CONCLUSION: Palliative care nurses need to examine their beliefs and practices in relation to how hospice inpatient care is prioritized, and develop sound evidence-based arguments in order to strengthen their role and influence in these important decisions for the benefit of patients. Further research is needed to achieve a greater understanding of these types of decision-making processes.     

Consultation audio-tapes: an information aid, and a quality assurance and research tool

Facilities for audio-taping medical consultations are widely available, and an increasing proportion of cancer patients request and/or appreciate the offer of an audio-tape after an oncology consultation. We have examined the usefulness to patients and their families of audio-tapes of initial and follow-up consultations. We have used consultation audio-tapes as a research tool investigating doctor-patient communication. Audio-tapes may ultimately find a place as an audit tool to monitor oncologist performance. We have audio-taped several hundred medical and radiation oncology consultations over the past 10 years. We have developed methods of analysing oncologist-patient communication and studied a variety of interventions designed to enhance communication in the cancer consultation. We have offered consultation audio-tapes to cancer patients after their initial oncology consultation and after routine outpatient follow-up appointments, and documented their use. Cancer patients and their family's value consultation audio-tapes as an information aid, and to assist recall. Consultation audio-tapes document information provision and allow analysis of oncologist-patient interaction in discussion of prognosis, treatment options and seeking/giving informed consent. Consultation audio-tapes have a role in providing feedback concerning oncologist performance. Oncologists should consider installing audio-tape-recording facilities and offer new and follow-up patients a taped consultation. Audio-tapes are a valuable tool in the investigation of oncologist-patient interactions.