ICU患者安宁疗护筛查工具的范围综述

目的 系统检索与分析ICU患者安宁疗护筛查工具,为ICU患者安宁疗护筛查提供参考。 方法 采用范围综述的研究方法,检索中英文数据库、指南网及相关专业网站,获取与ICU患者安宁疗护相关的筛查工具。 结果 纳入21篇文献,包含21种ICU患者安宁疗护筛查工具,其中普适性工具2种,专科性工具19种;筛查工具中出现频率较高的条目有：晚期/转移性癌症、住院时间/ICU住院时间、ICU入住次数≥2次、心脏骤停、多器官功能衰竭、晚期痴呆、治疗决策的分歧与冲突等。 结论 ICU患者安宁疗护筛查工具较多,但质量仍存在不足。可适当借鉴并结合我国国情研制筛查工具,以早期准确识别有安宁疗护需求的患者。     

安宁疗护知识量表的汉化及在中老年社区居民中的信效度检验

目的 汉化、修订安宁疗护知识量表，并在中老年社区居民中检验信效度，为测量社区居民安宁疗护知识水平提供有效工具。 方法 采用Brislin翻译模型对安宁疗护知识量表进行翻译和回译，并通过质性访谈增加条目内容，通过专家评议和预调查进行跨文化调适及内容修订。选取郑州市5个社区的364名中老年居民进行信效度检验。 结果 中文版安宁疗护知识量表为含20个条目的单维度量表，提取的1个公因子累积方差贡献率为62.739%；各个条目的共同度均大于0.4。条目水平的内容效度指数为0.875~1.000，量表水平的内容效度指数为0.980；量表Cronbach′s α系数为0.934，重测信度为0.808。 结论 中文版安宁疗护知识量表在中老年社区居民中具有较好的信度和效度，可用于测评社区居民安宁疗护知识水平。     

癌症患者安宁疗护需求问卷的编制及信效度检验

目的研制符合中国文化的癌症患者安宁疗护需求问卷,并检验其信效度。方法参考《安宁疗护实践指南(试行)》,以奥马哈问题分类系统为理论框架,通过文献研究、小组讨论、德尔菲专家函询得到初始问卷;采用方便取样法调查198例癌症患者对编制的问卷行信效度检验。结果最终形成包含28个条目的问卷;探索性因子分析共产生6个因子,累计方差贡献率为70.563%。问卷内容效度为0.933,各条目内容效度为0.813～1.000。问卷Cronbach′sα系数为0.934,重测信度为0.907。结论癌症患者安宁疗护需求问卷具有良好的信效度,可作为癌症患者安宁照护需求的评价工具。     

安宁疗护志愿者动机量表的汉化及信效度检验

目的 汉化安宁疗护志愿者动机量表,并检验其信效度,以期为我国安宁疗护志愿者动机测量提供工具.方法 应用Brislin模式对安宁疗护志愿者动机量表进行翻译,根据文化调适和预调查对量表进行修订,形成中文版量表.采用便利抽样方法对北京市、天津市260名安宁疗护志愿者进行调查,以检验中文版量表的信效度.结果 中文版量表包括利他主义、公民责任、自我提升、休闲和个人收益5个维度共25个条目.量表条目水平的内容效度(I-CVI)为0.833～1.000,量表水平的内容效度(S-CVI)为0.973;探索性因子分析共提取5个公因子,累积方差贡献率73.390％.量表的Cronbach's α系数为0.934,各维度的Cronbach'sα系数为0.896～0.917;折半信度为0.868;总量表的重测信度为0.913,各维度的重测信度为0.732～0.957.结论 中文版安宁疗护志愿者动机量表信效度良好,可作为评估我国安宁疗护志愿者动机的工具.     

ICU护士死亡态度在道德困境与安宁疗护核心能力间的中介效应

目的 调查ICU护士道德困境与安宁疗护核心能力现状，探讨死亡态度在两者间的中介效应。 方法 选取4所三甲医院的429名ICU护士为研究对象，采用一般资料调查问卷、中文版护士道德困境量表、中文版死亡态度描绘量表（修订版）及安宁疗护护士核心能力问卷进行调查。 结果 ICU护士道德困境、负向死亡态度、正向死亡态度与安宁疗护核心能力评分分别为（78.19±32.84）分、（40.21±9.02）分、（66.07±9.89）分、（70.21±20.88）分；道德困境与负向死亡态度呈正相关（r=0.500，P＜0.05），与正向死亡态度呈负相关（r=-0.496，P＜0.05），与安宁疗护核心能力呈负相关（r=-0.690，P＜0.05）；死亡态度在道德困境与安宁疗护核心能力间有部分中介作用（β=-0.332，P＜0.05），中介效应占总效应的42.78%。 结论 护理管理者需提高对ICU护士道德困境的关注，采取多样举措普及安宁疗护理念及死亡继续教育，着力改善道德环境，促使护理人员树立科学的死亡态度，提升安宁疗护服务能力。     

晚期癌症患者居家安宁疗护需求评估量表的编制及信效度检验

目的 编制晚期癌症患者居家安宁疗护需求评估量表并检测信效度。方法 以支持性照护理论框架为基础，通过质性访谈、德尔菲专家函询及小样本测试形成预试量表。采用便利抽样法，选取山东省5所医院425例选择居家安宁疗护的晚期癌症患者进行调查，检验问卷的信效度。结果 最终形成的正式量表包括日常生活照护需求、身体症状管理需求、心理照护需求、满足自我决定的需求、社会支持服务需求、灵性护理需求 6个维度共39个条目。探索性因子分析提取6个公因子，累计方差贡献率为79.742%；验证性因子分析显示，模型拟合度较好。总量表Cronbach′s α系数为0.962，折半信度为0.921，重测信度为0.945；总量表内容效度指数（S-CVI/Ave）为0.982。结论 晚期癌症患者居家安宁疗护需求评估量表具有较好的信效度，可作为居家安宁疗护需求的测评工具。     

安宁疗护沟通舒适度量表汉化及信效度检验

目的 对安宁疗护沟通舒适度量表进行汉化，并检验其在医护人员中应用的信效度。方法 依据跨文化调适指南对英文版量表进行直译、回译、跨文化调适、预调查后对量表进行修订，形成中文版安宁疗护沟通舒适度量表。采用便利抽样法对527名医护人员进行调查，检验中文版量表的信效度。结果 中文版量表包括团队考虑、处理医疗决策、精神考虑、处理症状、慎重意识、文化考虑共6个维度，累积方差贡献率为80.349%;条目水平的内容效度指数为0.860～1.000,量表平均内容效度指数为0.980;Cronbach′s α系数为0.910,重测信度为0.869。结论 中文版安宁疗护沟通舒适度量表信效度良好，可作为测量我国医护人员安宁疗护沟通舒适度的工具。     

安宁疗护自评实践量表的汉化和信效度检验

目的 汉化英文版安宁疗护自评实践量表,并对中文版量表进行信效度检验.方法 采用Brislin模式对量表进行正译、回译和跨文化调适.采用方便取样法调查武汉市2所三级甲等综合性医院的494名肿瘤科护士,检验量表的信效度.结果 量表的重测信度为0.890,Cronbach's α系数为0.909;量表水平的内容效度指数和条目水平的内容效度指数均为1;探索性因子分析提取3个公因子,累计方差贡献率为75.13％.结论 中文版安宁疗护自评实践量表具有较好的信度和效度,可以用于评估国内肿瘤科护士安宁疗护实践水平.     

终末期癌症患者自我报告安宁疗护照护质量问卷的编制及信效度检验

目的 编制、检验终末期癌症患者自我报告安宁疗护照护质量问卷，为评价照护质量提供适用性工具。方法 通过文献分析、小组讨论、德尔菲法、预调查形成问卷初稿；先后选取终末期癌症患者238例、254例进行问卷信效度检验与验证分析。结果 问卷包括5个维度共39个条目，探索性因子分析提取5个因子，累积方差贡献率为74.433%;验证性因子分析显示χ²/df=1.721,GFI=0.921,NFI=0.925,CFI=0.963,TLI=0.943,RMSEA=0.054。问卷总Cronbach′s α系数为0.950,折半信度为0.927,重测信度为0.830,内容效度指数为0.950。结论 该问卷具有良好的信效度，可用于评估终末期癌症患者安宁疗护照护质量。     

安宁疗护从业人员安宁疗护知信行现状及影响因素分析

目的 调查安宁疗护从业人员安宁疗护知信行现状并分析其影响因素,为安宁疗护教育培训提供参考.方法 采用 自行设计的安宁疗护从业者安宁疗护知信行问卷,选取1 743名安宁疗护从业人员进行调查.结果 安宁疗护从业者安宁疗护知信行总分为(74.28±8.12)分;学历、身体状况、月收入、对工作强度满意程度、安宁疗护管理制度为安宁疗护从业人员安宁疗护知信行水平的主要影响因素(P＜0.05,P＜0.01).结论 安宁疗护从业者安宁疗护知信行处于中等水平,均有提升空间,管理者需重视对安宁疗护从业者的培训,健全安宁疗护有关制度,提高从业人员的安宁疗护水平和服务质量.     

End-of-life care in the intensive care unit

The transition from active, invasive interventions to comfort care for critical care patients is often fraught with misunderstandings, conflict and moral distress. The most common issues that arise are ethical dilemmas around the equivalence of withholding and withdrawing life-sustaining treatment; the doctrine of double effect; the balance between paternalism and shared decision-making; legal challenges around best-interest decisions for patients that lack capacity; conflict resolution; and practical issues during the limitation of treatment. The aim of this article is to address commonly posed questions on these aspects of end-of-life care in the intensive care unit, using best available evidence, and provide practical guidance to critical care clinicians in the UK. With the help of case vignettes, we clarify the disassociation of withdrawing and/or withholding treatment from euthanasia; offer practical suggestions for the use of sedation and analgesia around the end of life, dissipating concerns about hastening death; and advocate for the inclusion of family in decision-making, when the patient does not have capacity. We propose a step-escalation approach in cases of family conflict and advocate for incorporation of communication skills during medical and nursing training.     

Stress in UK intensive care unit doctors

Background. Doctors have long been considered at risk of occupationalstress. Methods. A postal survey of all members of the Intensive CareSociety using validated instruments. Results. Eight-five per cent of members returned questionnairesand 70% were eligible for the study. Twenty-nine per cent weresuffering General Health Questionnaire-12 (GHQ-12) identifieddistress and 12% Symptom Checklist-Depression (SCL-D) defineddepression. There were no significant age or sex differencesbetween staff suffering distress or depression and those whodid not. Dissatisfaction with career correlated highly withboth distress and depression (P<0.01). Twenty doctors (3%)were bothered by suicidal thoughts. The most stressful aspectsof work were bed allocation, being over-stretched, effect ofhours of work and stress on personal/family life, and compromisingstandards when resources are short. Logistic regression revealedmental health problems were predicted by five stressors: ‘lackof recognition of one’s own contribution by others’;‘too much responsibility at times’; ‘effectof stress on personal/family life’; ‘keeping upto date with knowledge’; and ‘making the right decisionalone’. Conclusions. Nearly one in three ICU doctors appeared distressed(GHQ), and one in 10 depressed (SCL-D); this is no greater thanthat reported in other specialities. Perceived stressors revealsome key areas of concern for the employer and the specialty. Br J Anaesth 2002; 89: 873–81     

End-of-life care in the intensive care unit

End-of-life care in the intensive care unit (ICU) is an oxymoron. Intensive care units appeared in the 1980s only admitting patients for ‘intensive care’. Nowadays the ICU has become one of the few places in the hospital that can provide comfort care to the dying patient. For many doctors on ICU it remains a difficult and problematic area. Yet it is conceptually simple. The difficulty for the doctor is making the decision, for the patient and family, coming to terms with it. This article will focus on how this decision should be made and then on the care that should be provided for the patient. Many of the considerations in decision making are in the General Medical Council guidelines, Treatment and Care Towards the End of Life and this is essential reading before embarking of the process.     

National survey of palliative care in end-stage renal disease in the UK.

BACKGROUND: Palliative care for patients with end-stage renal disease (ESRD) is a neglected aspect of nephrology. We carried out this survey to establish the current pattern of provision of palliative care for ESRD in the UK. METHODS: An anonymous but numbered questionnaire concerning local palliative care provision was sent to clinical directors of all 69 UK renal units. RESULTS: All the questionnaires were returned. Only 27 (39%) units employ nursing or Professions Allied to Medicine (PAM) staff with palliative care for ESRD patients as a specified part of their role. In 19 of these units, staff spend <4 h per week concerned with palliative care and only five units have staff working for >12 h a week in this role. Fifty-five (80%) units do not have a written protocol for palliative care. Anaemic ESRD patients with an expected survival of >3 months receive blood transfusion in 59 (86%) units, intravenous iron in 61 (88%) units and erythropoietin in 63 (91%) units. Only 37 (54%) units kept a record of patients seen by the unit staff but deemed not suitable for dialysis. CONCLUSION: There is a significant variation in provision of palliative care services across the UK. In some areas, access to palliative care is restricted to patients with malignant disease, and ESRD patients are excluded.     

ICU and critical care outreach for the elderly

Average life expectancy has increased over the past century resulting in a shift in world population demographics. There are more elderly people alive now than throughout all of human history. The burden of comorbid disease and dependency rises with age and has been shown to independently predict need for hospitalization, institutionalization and mortality. Accordingly, there are more elderly persons living longer in more tenuous states of health. The relative proportion of patients admitted to hospital and intensive care who are elderly is considerable and recent data have suggested an increasing trend. There is likely significant selection bias amongst elderly patients triaged for access to finite critical care services. In fact, data have shown that elderly patients often receive less intensive therapy and have greater support limitations when admitted to an intensive care environment. "Chronologic" age has been an inconsistent predictor of prognosis in elderly patients who present with critical illness. However, surrogate measures of "physiologic" age are likely more relevant, such as an assessment of frailty, to aid in prognostication and informed decision-making and that ultimately correlate not only with short-term survival but additional outcomes such as functional status, institutionalization and quality of life after an episode of critical illness. There is a paucity of literature on the specific interaction of rapid response systems (RRS) and hospitalized "at-risk" elderly patients; however, the RRS may have particular application for this cohort. In particular, data have emerged to suggest mature ICU-based RRS respond commonly to elderly patients and are increasingly participating in end-of-life care discussions. In addition, another aspect of the RRS, critical care outreach (CCO), may facilitate the identification of elderly patients for timely goal-oriented advanced care planning prior to clinical deterioration.     

Intensive care of the elderly - a retrospective study

Access to intensive care is to a large extent a prerequisite of the treatment of increasingly old patients for more and more complicated diseases. The ultimate outcome of such treatment is little known, however. In this study we have followed up 143 patients (91 males and 52 females), aged 70 years or more, who were treated in the intensive care unit (ICU) of Danderyd Hospital for 48 h or more during the years 1979-1982. As a comparison, another group of 143 patients in all age groups treated in the ICU for 48 h or more were studied during 1 year (1980). The main diagnostic groups were infectious diseases, trauma, acute abdominal diseases, malignancy, cardiovascular diseases, and other diseases. The mean mortality within 12 months at age 70 years and above was 52%, highest for cardiovascular diseases (73%) and malignant diseases (60%). Within this age group, the main part of the occupancy in our ICU was held by patients who died within 18 months (58%). The results show that the ICU-cost per patient per year saved was not much higher for patients in diagnostic groups with higher mortality or longer duration of stay in the ICU than in other groups. Calculations of ICU-cost seem to be a relevant parameter for the evaluation of the results of ICU care. Fifty per cent of all patients were able to return home some time after intensive care. The humanitarian end result is thus encouraging, but better criteria for selection of patients are needed.     

Design,organization and staffing of the intensive care unit

The intensive care unit is at the heart of a hospital's acute services. It brings together almost all of the medical specialties alongside allied health professionals and support services. The design of intensive care units is complex and needs to be carefully thought out to provide the best environment for both patients and staff in order to maximize therapies and minimize risks. The level of organ support required dictates the level of support and staff needed to care for ach individual patient. Critical care units need to be flexible to the demands of a hospital and provide capacity when it is required.