Medical decisions concerning the end of life: a discussion with Japanese physicians.

OBJECTIVES: Life-sustaining treatment at the end of life gives rise to many ethical problems in Japan. Recent surveys of Japanese physicians suggested that they tend to treat terminally ill patients aggressively. We studied why Japanese physicians were reluctant to withhold or withdraw life-support from terminally ill patients and what affected their decisions. DESIGN AND PARTICIPANTS: A qualitative study design was employed, using a focus group interview with seven physicians, to gain an in-depth understanding of attitudes and rationales in Japan regarding medical care at the end of life. RESULTS: Analysis revealed that physicians and patients' family members usually make decisions about life-sustaining treatment, while the patients' wishes are unavailable or not taken into account. Both physicians and family members tend to consider withholding or withdrawing life-sustaining treatment as abandonment or even killing. The strongest reason to start cardiopulmonary resuscitation- and to continue it until patients' family members arrive-seems to be the family members' desire to be at the bedside at the time of death. All physicians participating in our study regarded advance directives that provide information as to patients' wishes about life-sustaining treatment desirable. All expressed concern, however, that it would be difficult to forego or discontinue life-support based on a patient's advance directive, particularly when the patient's family opposed the directive. CONCLUSION: Our group interview suggested several possible barriers to death with dignity and the appropriate use of advance directives in Japan. Further qualitative and quantitative research in this regard is needed.     

微意识状态患者视觉脑皮层活动的功能磁共振研究

目的探讨微意识状态患者是否保存大范围的视觉神经网络,是否存在视觉意识,从而研究视觉图片被动呈现刺激促进脑功能康复的可能性。方法正常对照组为10例健康成年男性,实验组为从重型颅脑损伤和脑出血中恢复的微意识患者9例;对两组对象选取标准化国际情感图片系统（IAPS）图片,采用组块设计被动呈现视觉刺激功能磁共振扫描,AFNI软件处理图像数据。结果10例正常对照志愿者全部被激活了初级视觉皮层枕叶和次级视觉相关皮层颞叶、梭回、顶叶、眶回、前额叶等完整的视觉神经网络。微意识患者组中有2例与对照组相似完整地激活了视觉神经网络。3例患者部分激活了视觉神经网络的相关区域,4例完全无脑区激活。结论IAPS图片的被动呈现视觉刺激功能磁共振扫描探讨视觉神经网络是可行的、可靠的和具有良好的重复性。微意识患者在恢复相互交流能力之前,可保留有完整的视觉神经网络,可能有利于脑功能的康复。     

Perceptions of patients on the utility or futility of end-of-life treatment

BACKGROUND AND OBJECTIVES: Definitions of medical futility, offered by healthcare professionals, bioethicists and other experts, have been rigorously debated by many investigators, but the perceptions of patients of futility have been explored only by a few. Patients were allowed to discuss their concerns about end-of-life care, so that their ideas about treatment futility or utility could be extrapolated by us. METHODS: In this cross-sectional study, in-depth, semistructured interviews were conducted with 30 elderly people who were receiving outpatient care in a large, urban Veterans Affairs medical centre in the US. Each of their healthcare providers was also interviewed. Participants were asked to consider four terms commonly used in advance directive forms (ie, life-sustaining treatment, terminal condition, state of permanent unconsciousness and decision-making capacity) and to discuss what these terms meant to them. Audiotapes of the open-ended interviews were transcribed and responses were coded and categorised by constant comparison, a commonly used qualitative method. RESULTS: The following four factors were taken into account by the participants when discussing end-of-life interventions and outcomes: (1) expected quality of life; (2) emotional and financial costs of treatment; (3) likelihood of treatment success; and (4) expected effect on longevity. CONCLUSIONS: Although the terms "utility" or "futility" were not generally used by the participants, segments of speech indicating their perceptions of these terms were identified. Treatment was not always discussed in the same way by patients and providers, but seemed to reflect the same four concerns. Therefore, it may be fruitful for providers to focus on these concerns when discussing end-of-life treatment options with their patients.     

Withdrawing life-sustaining treatment from severely brain-damaged persons

Ventilator support is commonly withdrawn from unconscious patients who cannot breathe when it is reasonably certain that their condition is permanent and further medical treatment is futile. However, there is no consistent practice with permanently unconscious patients who can breathe but cannot swallow, despite the fact that ongoing treatment of these patients is similarly futile. In both groups of patients, the withdrawal of treatment is not euthanasia, and the cause of death is properly considered to be the underlying illness. A review of the medical, legal and ethical literature shows that there is much disagreement about when and how to withdraw tube feeding from patients with severe brain damage. Criteria for withdrawal of treatment should include the permanent unconsciousness of the patient, the permanent absence of a life-sustaining function, the elapse of sufficient time to be certain about the prognosis, the concurrence of at least one independent and qualified medical specialist, and the informed consent of the patient's family or other legally qualified agents.     

甲状腺微小乳头状癌患者射频消融术后生活质量的相关影响因素分析

目的 评估甲状腺微小乳头状癌(PTMC)患者行超声引导下射频消融术后健康相关生活质量(HRQoL)的影响因素。方法 回顾性分析2019年10月至12月在中国人民解放军总医院超声诊断科进行射频消融术后复查的100例PTMC患者的临床资料,收集患者的人口学信息,采用SF-36和甲状腺癌特异性健康相关生活质量量表分别评估患者的生活质量和甲状腺相关特异性症状。SF-36量表包括躯体健康(PCS)和精神健康(MCS)两个总维度。分析人口学特征及射频消融术后甲状腺相关症状对PTMC患者SF-36量表中PCS及MCS分数的影响。结果 单因素及相关性分析结果显示,PTMC患者生活质量中PCS分数与性别、神经肌肉、声音、注意力、交感神经、喉咙和口腔、心理、感觉症状、瘢痕、感觉寒冷、刺痛感、头痛症状有关(P均<0.1);MCS分数与文化程度、常住地、神经肌肉、声音、注意力、交感神经、喉咙和口腔、心理、感觉症状、瘢痕、感觉寒冷、刺痛感、头痛症状相关(P均<0.1)。多因素线性回归分析表明,PCS分数仅与性别、心理、神经肌肉、喉咙和口腔的症状相关,回归方程为PCS=110.367-8.025×性别-0.213×心理-0.280×神经肌肉-0.278×喉咙/口腔;MCS分数仅与心理、喉咙和口腔、注意力集中的相关症状相关,回归方程为:MCS=91.323-0.237×心理-0.437×喉咙/口腔-0.304×注意力集中。结论 影响超声引导下射频消融术后PTMC患者生活质量的主要危险因素是女性患者、心理负担、注意力不集中、神经肌肉及喉咙口腔的相关症状。因此,应根据患者可能报告的相关症状做好术前交代,并在术后有针对性的进行心理干预,进而提高PTMC患者治疗后的生活质量。     

Not if, but how: one way to talk with patients about forgoing life support

May the common clinical conversation be used to explore whether or not seriously ill patients want to talk about possible limitations of life support? In order to answer this question, a series of 20 seriously ill patients took part in an interview. The clinical conversations were taped and transcribed, and recurrent themes were identified and organised into categories. After talking about their diagnosis and prognosis, most patients said it was natural to talk about possible limitations of life support, and a substantial number immediately indicated that they did not want any life-sustaining treatment. Although their emotional reactions were different, no one seemed to be upset by talking about such issues. Many but not all patients said that they wanted a family member and possibly also a nurse to participate in the conversation. Every doctor learns to conduct a clinical conversation and this approach may be applied when talking with seriously ill patients about difficult treatment decisions.     

Decisions to abate life-sustaining treatment for nonautonomous patients. Ethical standards and legal liability for physicians after Cruzan

The lives of hopelessly ill patients often are prolonged because physicians are uncertain of the legal consequences of discontinuing life-sustaining treatment, particularly when a patient lacks decision making capacity. Physician uncertainty may increase in the light of the U.S. Supreme Court's Cruzan decision, which upheld Missouri's refusal to support a family's request to discontinue tube feeding a patient in a persistent vegetative state. Weir, an ethicist, and Gostin, an attorney, examine the body of case law through Cruzan related to the issue of abating life-sustaining treatment for nonautonomous patients, including decisions on the right to refuse treatment, the role of surrogate decision makers, types of treatment that may be abated, and the threat of legal liability. They conclude that physicians need not fear the legal consequences of discontinuing life-sustaining treatment if an appropriate decision making process has been followed.     

应该对PVS病人进行生命维持吗？——庄子思想的启示

庄子的生命观消解了生命神圣论，主张以安时处顺、恬淡自然的态度提高生命质量；提醒人们应该清醒意识到生命的极限，反对对生命进行“遁天倍情”的妄为之举。现从庄子的生命观出发，将使解决这一伦理难题得到启示。     

Artificial nutrition and hydration in the patient with advanced dementia: is withholding treatment compatible with traditional Judaism?

Several religious traditions are widely believed to advocate the use of life-sustaining treatment in all circumstances. Hence, many believe that these faiths would require the use of a feeding tube in patients with advanced dementia who have lost interest in or the capacity to swallow food. This article explores whether one such tradition--halachic Judaism--in fact demands the use of artificial nutrition and hydration in this setting. Traditional (halachic) arguments have been advanced holding that treatment can be withheld in persons who are dying, in individuals whose condition causes great suffering, or in the event that the treatment would produce suffering. Individuals with advanced dementia can be considered to be dying, often suffer as a result of their dementia, and are likely to suffer from the use of a feeding tube. Given these observations and the absence of a compelling case for distinguishing between tube feeding and other forms of medical treatment, traditional Judaism appears compatible with withholding artificial nutrition for individuals with advanced dementia.     

高血压脑出血立体定向穿刺手术与保守治疗预后比较分析

目的分析高血压脑出血患者行立体定向穿刺手术与保守治疗预后对比。方法回顾分析70例高血压脑出血患者立体定向穿刺手术资料,筛选出60例同期内科保守治疗病例作对照,出血部位、出血量及入院时意识状况相匹配,对二组病例治疗结果进行对比分析。结果①病死率：立体定向手术组15.7%,内科治疗组23.3%。②血肿消失时间：立体定向穿刺手术组血肿消除时间平均5.3d,保守治疗组19.6d。③6个月随访结果：二组恢复良好、有轻度神经功能障碍、能正常生活的患者（P〈0.01）;二组重度病残,生活不能自理的患者对比（P〈0.01）;立体定向手术组优于内科保守治疗组。二组中度病残、生活能够自理患者对比（P〉0.05）,二组差异无统计学意义。结论立体定向穿刺手术治疗高血压脑出血在病死率以及提高患者生存质量方面优于内科保守治疗。     

Death with dignity and the right to die: sometimes doctors have a duty to hasten death.

As the single most important experience in the lives of all people, the process and event of death must be handled carefully by the medical community. Twentieth-century advances in life-sustaining technology impose new areas of concern on those who are responsible for dying persons. Physicians and surrogates alike must be ready and willing to decide not to intervene in the dying process, indeed to hasten it, when they see the autonomy and dignity of patients threatened. In addition, the very ways we talk about death and dying need to come under scrutiny, and it is likely that our technical advances should be parallelled by equally arduous advances in the semantic and rhetorical approaches we take to death.     

The decision making process regarding the withdrawal or withholding of potential life-saving treatments in a children's hospital

OBJECTIVES: To investigate the factors considered by staff, and the practicalities involved in the decision making process regarding the withdrawal or withholding of potential life-sustaining treatment in a children's hospital. To compare our current practice with that recommended by the Royal College of Paediatrics and Child Health (RCPCH) guidelines, published in 1997. DESIGN: A prospective, observational study using self-reported questionnaires. SETTING: Tertiary paediatric hospital. PATIENTS AND PARTICIPANTS: Consecutive patients identified during a six-month period, about whom a formal discussion took place between medical staff, nursing staff and family regarding the withholding or withdrawal of potentially life-sustaining treatments. The primary physician and primary nurse involved in the discussion were identified. METHOD: Two questionnaires completed independently by the primary physician and nurse. RESULTS: Twenty-two patients were identified (median age 1 year; range 1 day-34 years). In 20 cases treatment was withdrawn or withheld, in two cases treatment was continued. Nursing staff considered family wishes and family perceptions of patient suffering as significantly more important factors in decision making than medical staff, who considered prognostic factors as most important. In only two cases were the patient's expressed wishes apparently available. In most cases staff considered the patient's best interests were served and the process would not be enhanced by the involvement of an independent ethics committee. The exceptions were those cases in which treatment was continued following disagreement between parties. CONCLUSIONS: Our current practice is consistent with that recommended by the RCPCH. The contribution of the patient, provision of staff counselling and general practitioner (GP) involvement were identified as areas for improvement.     

Seven legal barriers to end-of-life care: myths, realities, and grains of truth

OBJECTIVE: The American College of Physicians-American Society of Internal Medicine (ACP-ASIM) End-of-Life Care Consensus Panel was convened in 1997 to identify clinical, ethical, and policy problems in end-of-life care, to analyze critically the available evidence and guidelines, and to offer consensus recommendations on how to improve care of the dying. Topic selection and content presentation were carefully debated to maximize the project's focus on providing practical clinical and other guidance to clinicians who are not specialists in palliative care. This statement examines current legal myths, realities, and grains of truth in end-of-life care. PARTICIPANTS: The Consensus Panel comprises 13 medical and bioethics experts, clinicians, and educators in care at the end of life selected by the Ethics and Human Rights Committee, College leadership, and the Center for Ethics and Professionalism at the ACP-ASIM. EVIDENCE: A literature review including a MEDLINE search of articles from 1970-1998 and review of end-of-life care literature and organizational bibliographies was conducted. Unpublished sources were also identified by participants, as was anecdotal clinical experience. CONSENSUS PROCESS: The draft statement was debated by panel members over a series of 3 to 4 meetings. For this statement, the initial draft and subsequent revised drafts were discussed in 1998-1999. The statement then underwent external peer review and revision before panel approval and the journal peer review process. CONCLUSIONS: Legal myths about end-of-life care can undermine good care and ethical medical practice. In addition, at times ethics, clinical judgment, and the law conflict. Patients (or families) and physicians can find themselves considering clinical actions that are ethically appropriate, but raise legal concerns. The 7 major legal myths regarding end-of-life care are: (1) forgoing life-sustaining treatment for patients without decision-making capacity requires evidence that this was the patient's actual wish; (2) withholding or withdrawing of artificial fluids and nutrition from terminally ill or permanently unconscious patients is illegal; (3) risk management personnel must be consulted before life-sustaining medical treatment may be terminated; (4) advance directives must comply with specific forms, are not transferable between states, and govern all future treatment decisions; oral advance directives are unenforceable; (5) if a physician prescribes or administers high doses of medication to relieve pain or other discomfort in a terminally ill patient, resulting in death, he/she will be criminally prosecuted; (6) when a terminally ill patient's suffering is overwhelming despite palliative care, and he/she requests a hastened death, there are no legally permissible options to ease suffering; and (7) the 1997 Supreme Court decisions outlawed physician-assisted suicide. Many legal barriers to end-of-life care are more mythical than real, but sometimes there is a grain of truth. Physicians must know the law of the state in which they practice. JAMA. 2000;284:2495-2501.     

健康相关生命质量高分组和低分组生活习惯和中医体质量表转换分比较

目的 探索健康相关生命质量高分组和低分组的生活习惯和中医体质转换分的差异。方法 从1 114例健康体检人群数据库中,分别抽取简明健康状况调查问卷（the MOS 36-item short form health survey, SF-36）的生理领域得分、心理领域得分的前27%（301例）和后27%（301例）作为高分组和低分组,比较两组的生活习惯和中医体质量表转换分。结果 SF-36生理领域和心理领域高分组和低分组的吸烟偏好比较,差异无统计学意义（P>0.05）;两组饮酒偏好、睡眠时间、中医体质量表转换分比较,差异具有统计学意义（P<0.05）,其中高分组好饮酒者较多,睡眠时间为7～8 h者较多,平和质者较多,平和质转换分较高,8种偏颇体质转换分较低;心理领域高分组有运动习惯者较多（P<0.05）,而生理领域高分组和低分组的运动习惯差异无统计学意义（P>0.05）。结论 SF-36高分组和低分组的生活习惯和中医体质因素存在一定差异,通过改善睡眠时间、运动习惯及偏颇体质可能会提高健康相关生命质量。     

全身麻醉手术下慢性意识障碍患者的临床特征及意识改善预测

目的 研究全身麻醉手术下慢性意识障碍(prolonged disorders of consciousness, pDOC)患者的临床特征，并探讨与患者术后意识改善的相关临床因素。方法 回顾性收集2022年2月至2022年12月pDOC患者择期手术围术期资料，应用Logistic回归探讨与术后意识改善的相关围术期临床因素。结果 研究纳入122例行择期全身麻醉手术的pDOC患者，其中包括植物状态患者72例(59.0%),微意识状态患者50例(41.0%),其中术后27例患者意识水平显著改善，使用Logistic回归模型校正年龄、美国麻醉医师学会身体状态分级(the American Society of Anesthesiologists Classification of Physical Status, ASA)、手术方式、舒芬太尼和瑞芬太尼使用剂量以及苏醒时间等相关变量后，发现术中舒芬太尼使用剂量(OR=17.23,95%CI:1.22～224.30,P=0.035)、苏醒时间(OR=1.03,95%CI:1.00～1.05,P=0.046)与患者术后意识状态改善相关。结论 pDO...     

Patients' and families' preferences for medical intensive care

Medical ethics suggest that life-sustaining treatment decisions should be made with consideration for patients' preferences and quality of life. Patients were interviewed who were at least 55 years old and had experienced medical intensive care at a university hospital during a one-year period to determine their preferences regarding intensive care; family members were interviewed if the patient had died (n = 160). Seventy percent of patients and families were 100% willing to undergo intensive care again to achieve even one month of survival; 8% were completely unwilling to undergo intensive care to achieve any prolongation of survival. Preferences were poorly correlated with functional status or quality of life and were not altered by life expectancy for 82% of respondents. Age, severity of critical illness, length of stay, and charges for intensive care did not influence willingness to undergo intensive care. These data suggest that personal preferences may conflict with any health policy that limits the allocation of intensive care based on age, function, or quality of life.     

The right to refuse treatment is not a right to be killed.

It is widely accepted now that a patient's right to refuse treatment extends to circumstances in which the exercise of that right may lead to the patient's death. However, it is also often effectively assumed, without argument, that this implies a patient's right to request another agent to intervene so as to bring about his or her death, in a way which would render that agent guilty of murder in the absence of such a request. But the right to refuse treatment can, logically, have no such implication, and the mistaken supposition that it does conflates a right to die with a right to be killed. Confusion over this issue is brought out by an examination of conflicting opinion concerning the permissible termination of ventilation for mentally competent patients. A wider lesson may be drawn regarding the need for the ethical assessment of new forms of life-sustaining medical technology.     

广东省城镇居民生存质量与亚健康的相关分析

目的 探讨广东省城镇居民生存质量与亚健康的关系.方法 应用生存质量量表SF-36和亚健康评定量表（SHMS V1.0）设计调查问卷,对2 200名广东省城镇居民开展现况调查.结果 男性城镇居民在PCS,MCS、身体症状、认知功能和社会适应领域得分[分别为（78.89±15.25）分,（73.15±15.26）分,（63.73± 18.82）分,（62.13± 19.34）分,（68.04± 17.90）分],高于女性得分[分别为（76.98±14.20）分,（71.76±14.72）分,（60.53± 18.28）分,（57.00± 17.89）分,（65.73± 17.07）分],差异有统计学意义（P＜0.05）.双变量相关分析显示,生存质量的PCS和MCS分别与亚健康各个维度呈正相关,差异有统计学意义（P＜0.001）.典则相关分析表明,精力（X4）、社会适应（X8）、身体症状（X1）、正向情绪（X5）等是体现亚健康状况的主要因素,心理内容综合测量（MCS）是反映生存质量的主要因素.结论 广东省城镇居民的生存质量与亚健康状况存在正相关关系,即亚健康状况愈严重,生存质量亦愈差,应根据调查情况有针对性地加强城镇居民亚健康状况及生存质量的干预.     

慢性消化性溃疡生命质量及患者报告结局的影响因素分析

目的：对慢性消化性溃疡（PU）患者进行生命质量测评,分析影响患者生命质量的因素。方法采用普适性量表———健康状况调查问卷（SF-36）作为调查工具,对120例 PU 住院患者生命质量进行测评。利用两独立样本 t 检验对患者的生命质量得分和全国常模进行比较。利用两独立样本 t 检验和方差分析,分别对不同性别、年龄、民族、职业、婚姻、医疗形式、经济状况、文化程度、治疗方法、临床类型的各领域得分进行比较分析。结果PU 患者除了精神健康（MH）领域之外其余7个领域以及躯体综合总分（PCS）、心理综合总分（MCS）得分均低于健康对照组,差异有统计学意义（P ＜0．05）;性别、年龄、经济状况、文化程度、医疗形式和治疗方法对 SF-36量表某些领域或者综合总分有影响,差异均有统计学意义（P ＜0．05）。结论找出影响 PU患者生命质量的因素,为今后临床治疗提供基础。     

基于主体-客体互倚模型分析结直肠癌患者和家庭主要照顾者的亲密关系对生活质量的影响研究

背景　2019年数据显示,中国结直肠癌防控形势严峻。在亲密关系背景下,癌症患者与家庭主要照顾者以一个整体单元共同适应癌症。疾病自身及治疗不仅会影响患者,造成其生活质量低下,还会严重影响与其具有亲密关系的家庭主要照顾者。目的　基于主体-客体互倚模型（APIM）分析结直肠癌患者和家庭主要照顾者的亲密关系对生活质量的影响,为临床干预提供理论依据。方法　采取便利抽样法选取2018年11月-2019年5月收治于南方医科大学南方医院、云南省肿瘤医院、中山大学附属第六医院的结直肠癌患者及其家庭主要照顾者作为调查对象。采用关系评估量表（RAS）测量结直肠癌患者和家庭主要照顾者过去7 d对所处的亲密关系各方面的主观满意度,采用中文版简明健康SF-12量表评定结直肠癌患者和家庭主要照顾者过去7 d的生活质量。并建立结直肠癌患者和家庭主要照顾者的亲密关系与生活质量的APIM,分析患者和家庭主要照顾者的亲密关系对生活质量的影响。结果　共发放296对问卷,有效问卷271对,有效回收率为91.6%。患者亲密关系得分与家庭主要照顾者的亲密关系、生理健康（PCS）及心理健康（MCS）得分均呈正相关（P<0.05）,患者PCS得分与家庭主要照顾者的PCS及MCS得分呈正相关（P<0.05）,患者MCS得分与家庭主要照顾者的MCS得分呈正相关（P<0.05）。APIM分析结果显示,在主体效应方面,家庭主要照顾者的亲密关系与自身MCS呈正相关（P<0.001）;在客体效应方面,患者的亲密关系和家庭主要照顾者PCS呈正相关（P<0.001）,家庭主要照顾者的亲密关系和患者PCS呈正相关（P<0.001）。结论　结直肠癌患者的亲密关系可以正向预测家庭主要照顾者的生活质量,家庭主要照顾者的亲密关系可以正向预测自身以及患者的生活质量。