缓和医疗中缓和镇静的研究进展

缓和镇静是缓和医疗中控制痛苦症状的最后手段。缓和镇静适用于处于终末期、已接受系统性缓和医疗服务、存在顽固性症状且该症状产生无法忍受痛苦的患者。缓和镇静存在严格的适应证和决策流程。但我国尚无相关指南出台,且医护人员对其认知欠缺。本文将汇总国内外相关文献,就缓和镇静国内外发展现状、定义、分类、适应证、规范决策流程和常用策略等进行综述,旨在为我国缓和镇静的规范应用提供参考。     

The principle of double effect in palliative care

Caregivers sometimes feel powerless in complex end-of-life situations. Some therapies used to relieve the patient can have the effect of shortening the patient's life. This is why it is essential to explain clearly the principle known as the double effect.     

A method of calculating the value of palliative care of cancer patients

There are no entirely satisfactory methods for measuring the value of palliative treatment of advanced cancer. A useful instrument of measurement should take into account both length and quality of survival. A method is proposed for determining the area under the time-quality of life curve, using Simpson's discrete approximation, an algorithm which can be programmed simply into a small computer or programmable calculator. The Karnofsky index has been used as an indicator of the quality of life, but the method is adaptable to other quality of life scales. Efficiency of palliation can be estimated by comparison with the area produced by theoretically perfect palliation. The ability to quantitate palliation in these ways might help to resolve uncertainties that surround the alternative methods of management of incurable cancer.     

The value of trauma registries

Trauma registries are databases that document acute care delivered to patients hospitalised with injuries. They are designed to provide information that can be used to improve the efficiency and quality of trauma care. Indeed, the combination of trauma registry data at regional or national levels can produce very large databases that allow unprecedented opportunities for the evaluation of patient outcomes and inter-hospital comparisons. However, the creation and upkeep of trauma registries requires a substantial investment of money, time and effort, data quality is an important challenge and aggregated trauma data sets rarely represent a population-based sample of trauma. In addition, trauma hospitalisations are already routinely documented in administrative hospital discharge databases. The present review aims to provide evidence that trauma registry data can be used to improve the care dispensed to victims of injury in ways that could not be achieved with information from administrative databases alone. In addition, we will define the structure and purpose of contemporary trauma registries, acknowledge their limitations, and discuss possible ways to make them more useful.     

Medicare's bundling of trauma care codes violates relative value principles

BACKGROUND: Physician payment by Medicare is based on a Resource-Based Relative Value Scale (RBRVS). The Correct Coding Initiative (CCI) was introduced to counter unbundling by pairing component procedures with more comprehensive procedures. We hypothesized that Medicare's rebundling process ignored relative value concepts. METHODS: CCI tables were downloaded from Medicare's website. Each comprehensive code's Relative Value Units (RVUs) were compared with component RVUs. Trauma, Burn, and Critical Care (TBC) surgeon charges were analyzed to determine whether component services had higher RVUs than the comprehensive charge. RESULTS: 2,990 component CPT codes had total RVUs exceeding the RVUs of their paired comprehensive codes. If the undervalued comprehensive codes had been valued at their highest component's value, the minimum additional revenue would have been $211,600.59 per surgeon per year. CONCLUSION: A relative value scale depends upon equity in value units. Disregarding RVUs when bundling services and procedures results in severe physician underpayment.     

The value of trauma centres: a methodologic review

This review examines the rationale for the development of trauma centres in North America. The value of local and regional trauma care systems is considered, emphasizing study methodology. Evidence is acquired from case-series reports, before-and-after studies and intersystem comparisons. It overwhelmingly suggests that the main determinants of survival, given the severity of the injury, are the adequacy of the initial resuscitation and the early recognition of serious injuries. Thus, doctors involved in front-line trauma care, whether in the centre-city teaching hospital or in the rural community setting, must be properly prepared.     

Nerve blocks in palliative care

Although between 85% and 90% of patients with advanced cancer can have their pain well controlled with the use of analgesic drugs and adjuvants, there are some patients who will benefit from an interventional procedure. This includes a variety of nerve blocks and also some neurosurgical procedures. Approximately 8-10% of patients may benefit from a peripheral nerve block and around 2% from a central neuraxial block. The most common indication is because opioid dose escalation is limited by signs of opioid toxicity but some patients will benefit from one component of their pain being relieved by a simple peripheral block. Most patients about to undergo these procedures are already taking high doses of opiods and obtaining valid consent may pose problems. The use of peripheral nerve blocks, epidural and intrathecal infusions, and plexus blocks is discussed.     

The palliative care day hospital mobile team

The mobile continuous care and support team works with patients receiving palliative care. The palliative care day hospital, a new place of life, offers space and time to respond to the needs of the patient and his/her family in an approach which blends technical aspects and support.