Caring for Patients at Either End of Life

PREVIEW

Screening can be crucial for timely identification of lung cancer and thus for early treatment and a favorable prognosis. This conclusion is true particularly for persons at high risk for lung cancer, including those exposed to asbestos or silicon dust. In this article, Drs Bechtel and Petty discuss the types of screening procedures available, their cost, and the approaches and timing that are most beneficial to the public as a whole.     

自我管理教育对提高腹膜透析患者生存质量的影响

目的探讨自我管理教育对腹膜透析患者生存质量的影响。方法对40例规律腹膜透析≥6个月、病情稳定的患者进行为期6个月的自我管理教育,比较教育前后患者透析充分性、营养状况、生活质量、康复状况、自我管理能力和自我效能水平等各项指标的变化。结果教育期间,患者的透析充分性指标、营养指标均有提高（P〈0．01）,生活质量、康复状况亦有改善（P〈0．01）,自我管理能力和自我效能水平有提高（P〈0．05）。结论自我管理教育可以提高腹膜透析患者的自我管理能力和自我效能,从而改善患者的生存质量。     

The Gut in Older Patients on Peritoneal Dialysis

Age-related changes in gastrointestinal symptoms need to be considered in peritoneal dialysis (PD) patients. A diminishing appetite is associated with aging and may be exacerbated by renal failure and PD treatment, meaning that attention to dietary adequacy is important in the older patient. Constipation and its treatment may increase the risk of peritonitis, but is important for comfort as well as trouble-free dialysis. Diverticulosis increases with age, and whilst there may be ethnic differences in the patterns of this condition, there is conflicting evidence regarding the risks of peritonitis associated with asymptomatic disease. Hernias, urinary incontinence, and prolapse are also common and made worse by PD, so it is important to know about these issues prior to starting. Whilst data around these topics are scant and some studies conflicting, further understanding these issues and considering mitigation strategies may improve technique survival and quality of life.     

The Standard of Care and conflicts at the End of Life in critical care: Lessons from medical-legal crossroads and the role of a quasi-judicial tribunal in decision-making

Purpose

The goals of this qualitative study were to review the last 7 years of end of life legal decisions within the critical care field to explore how medical benefit is defined and by whom and the role of the standard of care (SoC) in conflict resolution.

Methods

A public online, non-profit database of the Federation of Law Societies of Canada was searched for relevant Consent and Capacity Board decisions from 2003 to 2012. In total, 1486 cases were collected, and purposive sampling identified a total of 29 decisions regarding use of life-sustaining treatments at end of life. Using modified grounded theory, decisions were read and analyzed from a central SoC concept to understand definitions of benefit, rationales for case adjudication, and repercussions of legal recourse in conflict resolution.

Results

Medical benefit was clearly defined, and its role in determining SoC, transparent. Perceptions of variability in SoC were enhanced by physicians in intractable conflicts seeking legal validation by framing SoC issues as “best interest” determinations. The results reveal some key problems in recourse to the Consent and Capacity Board for clinicians, patients and substitute decision makers in such conflict situations.

Conclusions

This study can help improve decision-making by debunking myth of variability in determinations of medical benefit and the standards of care at end of life and reveal the pitfalls of legal recourse in resolving intractable conflicts.     

社会回归对腹膜透析患者生活质量的影响

目的了解腹膜透析患者社会回归及生活质量状况,分析不同社会回归状况对腹膜透析患者生活质量的影响。方法2005年6月—2008年6月西安交通大学医学院第一附属医院肾内科腹膜透析门诊随访的透析时间6个月以上的患者100例。将患者社会回归状况分为4级,用健康调查简表（the MOS Item Short from Health Survey,SF-36）评估患者生活质量状况、用karnofsky活动指数评定患者活动状况、主观营养评估评价营养状况,比较不同社会回归状况患者生活质量、活动状况和营养状况的差异。结果100例门诊腹膜透析患者中,社会回归1级16例,2级42例,3级32例,4级10例。不同社会回归级别患者SF-36中生理健康、生理角色、健康总体自评、活力维度得分,以及karnofsky活动指数、主观营养评估结果差异有统计学意义。社会回归与年龄、主观营养评估呈负相关,与血红蛋白、白蛋白、Karnofsky活动指数呈正相关（P〈0.05或P〈0.01）。结论社会回归级别较高的腹膜透析患者,其生活质量较好。社会回归的程度受患者的营养状况、心理状况、活动能力影响,提高社会回归程度有利于改善患者生活质量。     

The Needs of Older Patients for Peritoneal Dialysis: Training and Support at Home

Chronic kidney disease (CKD) in all its stages has become an important problem for older patients, stage 3 – 5 is expected to happen in 25 to 30% of the population, and a higher prevalence can be found in residential care and nursing homes, affecting the demand for patient education. Although older patients are able and keen to learn, there are specific needs that must be addressed. The focus of this paper is to review the demands to train and maintain older patients on peritoneal dialysis (PD) at home.     

家庭护理干预对腹膜透析患者生活质量的影响

目的探讨家庭护理干预提高腹膜透析（PD）患者生活质量的效果.方法选择2002年7月至2005年7月在中国医科大学附属第一医院肾内科出院的腹膜透析患者（n=80）,用随机数字表法分为实验组40例和对照组40例.对照组按常规定期复查,实验组在此基础上以定期家访和电话访问的形式进行家庭护理干预,包括为患者及家属提供心理咨询、健康教育、护理指导等,每周1次,每次30～60 min,持续时间为3个月.干预前后采用WHO推荐的健康调查简易量表Mos SF-36测评两组患者的生活质量.结果80例患者均进入结果分析.实验组患者干预后生理机能、角色生理、心理健康状况、角色心理状况、活力、躯体疼痛、主观健康状况得分分别明显高于干预前（t=2.1922～6.0236,P＜0.05）,亦高于对照组（t=2.0364～5.0622,P＜0.05）,差异有统计学意义.两组社会机能无统计学差异（P＞0.05）.结论家庭护理干预有效地提高了患者的生活质量.     

老年终末期肾病维持性腹透与血透患者生活质量比较

目的 比较老年持续性不卧床腹膜透析(CAPD)与维持性血液透析(HD)治疗的患者生活质量(Qol),寻求提高老年终末期肾病患者生活质量的最佳透析方法。方法 运用KDQOL-SFTMV1.3量表,在2008年-2009年期间,采取患者应答,医护人员记录的方式,对106例老年(年龄≥65岁,透龄≥3月且≤3年)患者进行Qol评估,其中CAPD组56例,血透组50例。根据Hays R.D.提供的记分方法进行评分,并运用SPSS15.0软件包对数据进行统计分析。结果 CAPD组与维持性血透组总体上生活质量相类似,但在个别单项得分上存在差异。源于SF-36项目中HD组体力状况(65.60?24.26)、体力因素对工作的影响(36.50?39.52)得分高于CAPD组,P<0.05;而CAPD组在情绪精神状态对工作的影响(48.67?44.78)得分高于HD组,P<0.05。源于KDTA中HD组在症状与不适(79.21?11.52)、睡眠状况(65.90?15.74)得分高于CAPD组,P<0.05;而CAPD组在工作状况(44.29?26.49)、透析医护人员的鼓励和支持(93.93?11.49)得分高于HD组,P<0.05。结论 两种透析方法对老年终末期肾病患者的生活质量均有所改善,但在生活质量的不同方面存在差异。     

The International Observatory on End of Life Care

The development of palliative care is proceeding rapidly in some areas of the world, but major problems continue to exist in several countries and regions. Comparative research evidence to inform palliative care development is limited and can be difficult to obtain, especially for resource poor settings. International collaboration is needed to promote and disseminate an evidence base to support the growth of palliative care. The aims and plans of the newly created International Observatory on End of Life Care are described, together with its orientation to global partnership and collaboration. The Observatory will build on public health models to provide research-based intelligence about palliative care around the world, drawing also on cultural, historical and ethical perspectives.     

End of Life Care and Decision Making: How Far We Have Come,How Far We Have to Go

While enormous progress has been made in improving the quality of care and the decision-making process for patients at the end of life, as a society we still have far to go to ensure that dying patients and their families have a comfortable and dignified death. In particular, reexamination and reconfiguration of our current decision framework is essential as our elderly population with chronic disease and slowly fatal conditions expands. With less certain disease paths and more complex and ambiguous choices, the growth of this geriatric population challenges us to develop a broader conceptualization of end of life care planning, so that end of life considerations are integrated into a larger anticipatory framework addressing options and needs as patients gradually decline. Within this framework hospice becomes a natural, integrated option along a continuum of care planning, rather than an abrupt alternative at a late stage of illness. End of life care planning must positively anticipate a robust array of needs and concerns well beyond the dramatic decisions to withhold or withdraw life-prolonging technologies usually found in advance directives. To embrace this broader framework it is critical that primary care physicians as well as disease specialists receive training in fundamental aspects of both geriatric and palliative care. Professionals from both of these disciplines must share expertise with each other, and should collaborate in advocacy efforts to effectuate changes in the clinical, policy and legislative arenas. [Article copies available for a fee from The Haworth Document Delivery Service: 1-800-342-9678. E-mail address: getinfo@haworthpressinc.com <Website: http://www.haworthpressinc.com>]     

Nutrition in Older Adults on Peritoneal Dialysis

Nutrition in older adults on peritoneal dialysis is an important aspect of a patient''s clinical management as well as being influenced by their overall well-being, both mental and physical. This is especially pertinent as individuals age, since the potential impact of life changes and physical changes contribute to the development of protein-energy wasting and potentially exacerbating sarcopenia and wasting. This article provides an outline of the nutritional issues to consider in older adults on peritoneal dialysis (PD).     

Patients' Autonomy at the End of Life: A Critical Review

Context

The predominating definition of autonomy as a capacity to make an independent rational choice may not be suitable for patients in palliative care. Therefrom arises the actual need for more contextualized perspectives on autonomy to promote the quality of life and satisfaction with care of terminally ill patients.