宁养医疗服务与有尊严的死亡

随着科技的进步和文明的发展,临终与死亡问题越来越受到人们的关注.而医疗水平的提高以及人口的逐渐老龄化则使得终末期疾病患者的数量持续增加,病程延长.终末期患者的宁养医疗服务又称之为安宁缓和医疗,旨在最大程度的减轻惠者的痛苦、避免无谓的治疗从而提高生活质量并做到有尊严的死亡.目前国内在该领域的研究起步较晚,投入尚嫌不足,存...     

糖尿病肾病终末期肾病治疗的现状

糖尿病肾病终末期肾病治疗的现状谢红浪综述季大玺审校关键词糖尿病肾病终末期肾病合并症糖尿病肾病（ＤＮ）是临床的一大难题，尽管目前医疗技术有很大发展，仍有许多患者病情进展迅速乃致短期内死亡。ＤＮ进入终末期肾病（ＥＳＲＤ）后，控制血糖和血压任务更加艰巨，且...     

系统指导对终末期肾病患者血液透析的体会

随着医疗技术的发展，经济条件的允许，血液透析（hemodialysis，HD）已被绝大多数终末期肾病的病人所接受，越来越多的终末期肾衰患者依赖透析生存并长期存活^[1]。终末期肾病是无法治愈的疾病，患者需要依靠透析维持生命，但是血液透析作为一种负性生活事件，使患者产生明显的悲观、恐惧、抑郁、不合作等行为；同时患者对疾病本身不正确认识或因经济问题不能正规进行血液透析治疗而导致严重的并发症，甚至死亡。因此，我院血液净化部对50例终末期肾病患者进行系统的血液透析指导，取得良好的效果，现报告如下。     

终末期肾病与心脏性猝死

终末期肾病患病率的上升和病死率增高是当前慢性病防治的重点。发生心脏性猝死是终末期肾病患者死亡的主要原因。明确其危险因素,进行有效防治对提高患者存活率意义重大。本文主要对终末期肾病患者中心脏性猝死的发生机制、危险因素、预防及管理做一综述。     

细节管理在终末期糖尿病肾病护理中的应用观察

目的观察在终末期糖尿病肾病护理中应用的细节管理的治疗效果。方法选取50例终末期糖尿病肾病患者进行临床疾病的观察分析。结果经过上述的治疗后,50例终末期糖尿病肾病患者在临床上的治疗中疾病的并发症发生率明显的改善,护理服务的满意度相对于治疗前明显的提高(P0.05)。结论终末期糖尿病肾病在临床上的治疗应用细节管理护理,能够有效的降低患者疾病并发症的发生率,提高临床护理服务的满意度,临床治疗效果显著。     

活体肝移植供体围术期安全问题研究进展

肝移植作为终末期肝病的有效治疗手段,给许多终末期肝病患者带来生的希望.但由于供体器官的短缺,有相当多的患者在等待中死亡.活体肝移植解决了供肝匮乏的问题,将成为未来肝移植的发展方向.     

要大办医疗保健服务的“4S店”

<正>我们的医院规模越办越大,出现了5000至近万张床位的巨无霸型超大规模医院;患者越来越多,患病年轻化;医疗成本快速攀升,大型医院年毛收入已达到数十亿,都花在患病后急性事件处理和终末期的救治,如不控制,终将导致医疗服务无钱可用;医患关系紧张,无有效解决方案。目前的这种医疗服务模式是坐堂行医,等人得病。没病的等得病,得病的等复发。政府投入越多,医疗资源浪费越大。患者越多,医生越忙,看病时间越短,医疗环境越差,社会对医疗机构的满意度     

远程医疗应用于射血分数保留性心力衰竭的现状及进展

慢性心力衰竭是多种心血管疾病的终末期表现,也是主要的死亡原因。其中射血分数保留性心力衰竭(heart failure with preserved ejection fraction,HFp EF)患者发病率占一半以上,且人数逐年增加。就目前而言,对于HFp EF的重视程度不够,现阶段临床上还无明确的治疗方法。20世纪90年代中期以来,以互联网信息技术为基础的远程医疗模式逐渐被引入,并在慢性心力衰竭患者的医疗管理方面取得了不同程度的认可。随着远程医疗新理念的产生,现就远程医疗对于HFp EF患者的意义做一综述。     

浅谈终末期糖尿病肾病患者的护理效果观察

目的探讨糖尿病终末期肾病患者的临床护理方式,对患者的临床护理有效性进行探讨分析。方法 2015年1月—2016年2月该院对糖尿病肾病终末期患者62例进行了分析研究,为患者提供全面护理,对护理进行总结,探讨护理问题。结果患者接受了护理服务,护理前和护理后的血肌酐和尿素氮水平对比差异有统计学意义(P0.05)。护理的关键还是在于及时地对问题进行发现和处理,终末期患者的病情控制是否良好,患者存在个体差异性,因此在进行护理的时候,需要结合患者的情况,改善患者的生存质量,针对性护理有助于患者的恢复。结论糖尿病肾病终末期患者的护理核心是怎样进行全面护理,改善患者的护理环境,提升临床护理质量。     

心绞痛急性发作期的社区救治策略

随着人们生活水平不断提高,人均寿命迅速增长,老年人口及其比例也不断增加,我国现在、已进入老年型社会。各种慢性病已占疾病谱和死亡谱的主流地位,短期住院治疗已无法解决患者的问题,因此连续性医疗保健对慢性病具有重要意义。我社区医疗服务中心对社区内的心绞痛急性发作期患者采取连续性治疗措施并取得较好效果,现报道如下。     

Twenty years beyond medical school: physicians' attitudes toward death and terminally ill patients.

BACKGROUND: In response to consumer demands and recent changes in health care, the American Medical Association and the Association of American Medical Colleges have expressed concern about how physicians relate to patients, especially those who are seriously ill. OBJECTIVE: To determine the impact of 20 years of medical practice on the attitudes of physicians toward terminally ill patients and their families. METHODS: Data were gathered from questionnaires mailed in 1976 and again in 1996 to physicians who graduated from medical school between 1972 and 1975. RESULTS: Responses were received from 71% and 63% of the 1664 and 1109 physicians surveyed in 1976 and 1996, respectively. Using a t test for paired variables, statistically significant differences were noted for physicians' responses to all of the 11 Likert-type attitudinal statements on death and terminally ill patients and their families. Physicians in 1996 were more willing to inform terminally ill patients of their prognosis and in general seemed more confident with dying patients than they were in 1976. CONCLUSIONS: After 2 decades of practicing medicine, physicians' attitudes toward terminally ill patients seem to have changed; physicians appear to be more open to communicating with terminally ill patients and their families on issues concerning death and dying.     

Assessing and managing depression in the terminally ill patient. ACP-ASIM End-of-Life Care Consensus Panel. American College of Physicians - American Society of Internal Medicine

Psychological distress often causes suffering in terminally ill patients and their families and poses challenges in diagnosis and treatment. Increased attention to diagnosis and treatment of depression can improve the coping mechanisms of patients and families. This paper reviews the clinical characteristics of normal grief and clinical depression and explains strategies for differential diagnosis. Although some literature discusses the psychological issues facing elderly patients and terminally ill patients with cancer, less is known about patients with end-stage pulmonary, cardiac, renal, and neurologic disease. Data on the effectiveness of interventions in terminally ill patients are lacking. Treatment recommendations in this paper represent extrapolations from existing literature and expert opinion. Diagnosing and treating depression in terminally ill patients involve unique challenges. Evidence of hopelessness, helplessness, worthlessness, guilt, and suicidal ideation are better indicators of depression in this context than neurovegetative symptoms. Although terminally ill patients often have suicidal thoughts, they are usually fleeting. Sustained suicidal ideation should prompt a comprehensive evaluation. Clinicians should have a low threshold for treating depression in terminally ill patients. Psychostimulants, because of their rapid onset of action, are useful agents and are generally well tolerated. Selective serotonin reuptake inhibitors and tricyclic antidepressants may also be used. Psychological interventions-including eliciting concerns and conveying the potential for connection, meaning, reconciliation, and closure in the dying process-can also facilitate coping.     

Delirium in the terminally ill

Delirium is highly prevalent in terminally ill patients, especially in the last weeks of life, when some cognitive impairment develops in as many as 85% of patients. Delirium is associated with increased morbidity in terminally ill patients and can interfere with pain and symptom control. The cause of delirium is usually multifactorial and often cannot be found or reversed in dying patients. Nonpharmacologic and pharmacologic interventions are effective in controlling the symptoms of delirium in terminally ill patients. Haloperidol and other newer neuroleptics are safe and effective in eliminating delirium for some patients. In approximately one third of patients, delirium can be managed successfully only by providing sedation.     

Managing end-of-life care: comparing the experiences of terminally Ill patients in managed care and fee for service

There have been no published empirical studies comparing the experiences of terminally ill patients in managed care organizations (MCOs) and those in fee for service (FFS). This investigation represents the first empirical study to systematically compare substantive outcomes between populations of terminally ill patients enrolled in MCO and FFS healthcare delivery systems. The investigators interviewed 988 patients whose physicians judged them to be terminally ill and 893 of their caregivers. Outcomes assessments were made in six domains: patient-physician relationship; access to care and use of health care; prevalence of symptoms; and planning for end-of-life care, care needs, and economic burdens. Overall, the two populations of terminally ill patients were found to have comparable outcomes, but several significant differences were present. MCO patients were more likely than their FFS counterparts to use an inconvenient hospital (P =.02), spend more than 10% of their income on medical care (P =.02), and have been bedridden more than 50% of the time during the last 4 weeks of life (P =.03). Caregivers of MCO patients were as likely as the caregivers of FFS patients to report a substantial caregiving burden (P =.59). Despite concerns about the threats of MCOs to the physician-patient relationship, few differences in the quality of the relationship between the two cohorts were found. Finally, terminally ill patients in MCOs did not show better experiences than those in FFS on any outcome measure. Additional research is required to explore how MCOs may improve upon the care available to dying patients.     

The effect of care of terminally ill patients' families on care of families attending patients' deathbeds in a general ward

AIM: Care of families attending patients' deathbeds is important, leading to care of the bereaved. However, we have no knowledge of a causal relationship between factors of care of terminally ill patients' families and care of families attending patients' deathbeds. The aim of this survey was to find out which factors of care nurses provide to terminally ill patients' families affect care of families attending patients' deathbeds in a general ward where many terminally ill elderly patients spend their time. METHODS: Questionnaire survey of 978 general ward chief nurses working for hospitals with over 100 beds in the Kyushu district. Data were processed through factor analysis and covariance structured analysis. RESULTS: 236 valid responses were analyzed. Four factors regarding chief nurses providing for families of terminally ill patients were identified. These factors were interpreted as first, mediating communication between families and patients; second, providing information; third, promoting cooperation and understanding among families; and fourth alleviating restrictions. The first factor correlates with the third factor. Especially, the first factor strongly affects the provision of care to families attending patients' deathbeds. The relationships of the second and fourth factors with care of families attending patients' deathbeds were not proved. CONCLUSION: Care of terminally ill patients' families in a general ward consists of four factors: mediating communication between families and patients, providing information, promoting cooperation and understanding among families, and alleviating restrictions. It was revealed that the more nurses promote cooperation and understanding among families, the more they can mediate communication between families and patients and provide care to families attending patients' deathbeds. It suggests that nurses are able to have a positive effect on the grief process of the bereaved by intervening between patients and families.     

Case Studies of Psychotherapy with Dying Persons

This paper briefly discusses several theoretical models in the field of thanatology and indicates how they can be applied clinically (through psychotherapy) to facilitate preparation for death in terminally ill patients. Factors to consider when doing psychotherapy with such patients include nearness to death, potential involvement of family members, and most importantly, the patient's emotional needs. Since the area of psychotherapy with the terminally ill is a relatively new field, we conclude with several recommendations for future research and clinical investigation.     

死亡教育对老年晚期癌症患者情绪状态与生活质量的影响

目的探讨死亡教育能否改善老年晚期癌症患者的情绪状态及生活质量。方法入选北京老年医院肿瘤内科97例老年晚期癌症患者,给予个体化死亡教育,年龄(68.32±8.78)岁,每周1~2次,持续4周,教育前后均接受简明心境量表(POMS)和生活质量测定表(EORTCQLQ-C30)评估。结果死亡教育后患者的紧张-焦虑、抑郁-沮丧、愤怒-敌意、慌乱-迷惑等情绪因子分值有显著降低,差异有统计学意义(P0.001);死亡教育后患者情绪功能、认知功能、社会功能及总体生存质量均有显著提高(P0.001)。结论死亡教育解除了患者对死亡的恐惧、担忧和悲观情绪,提高其生活质量。     

Terminal sedation. Ethic aspects

For better or for worse, bioethics is a discipline that, on occasion, presents more doubts and questions than solutions or answers for the variety of issues it implies. Sedation-as it concerns the terminally ill patient-is a clear example of one such issue. Sedation, used to diminish the intense suffering of those terminally ill patients who do not respond to conventional treatment, is a standard method by which the practice of palliative care presents often significant bioethical conflicts. I reconsider these ethical dilemmas that occur as a result of this decision.     

Drug-associated deaths of medical inpatients.

Of 7,423 medical inpatients, 16 (0.22%) died of drug-associated causes. The overall mortality for all medical inpatients was 6.5%. Eleven of the 16 patients who died of drug-associated causes had been terminally ill; the rest had been seriously ill before the fatal drug reaction occurred. Half of the patients had had either hematologic malignant changes or lupus nephritis. Antineoplastic drugs, azathioprine, prednisone, and heparin sodium were the most frequently implicated drugs. In other studies, we have found widely differing incidences of fatal drug reactions, due to a number of different drugs; these disparities are probably related to variations in the types of illnesses amoung different hospital populations and to varying interpretations of the term "drug-associated death." Extrapolation from the available data to a national incidence of drug-associated deaths is not possible. Drug-associated deaths are relatively uncommon and usually occur in the cases of severely or terminally ill patients treated with potentially highly toxic drugs.