瀕死的病人

TheDyingPatientTerenceL.Gutgsell,MDHospiceoftheBluegrassLexington,Kentucky生理學的變化癥狀的處理PhysiologicChangesSymptomManagement1目的

Objectives識別、評估、并處理瀕死病人的病學理生理學變化Recognize,assess,andmanagethepathophysiologicchangesofdying2家庭成員的引證

FamilyMember’sQuote“過去數(shù)年的個人經(jīng)歷使我明白了一個人的最后幾天會在人的記憶中留下永久的烙印。失去所帶來的痛苦依然是很強烈的，但是當感受到所有可以做的都做了，而且所有的職業(yè)照護者都以專業(yè)知識、職業(yè)道德、奉獻精神和愛心對病人給予了姑息關懷，讓患者能夠在他們所深愛的人的關懷下沒有痛苦地和舒服地死亡，我們心中就充滿了無限的感激和對這一醫(yī)學領域的敬畏?！薄癕ypersonalexperienceofthepastfewyearshastaughtmethatthoselastfewdayscolorone’smemoriespermanently.Thepainoflossisstillimmense,buttofeelthateverythingthatcouldhavebeendonewasdone,thatthosewhocareddidsowithknowledge,professionalism,devotion,andevenlove,andthatthepersondiedwithoutpain,comfortably,withthosetheylovedaroundthem,istofeelimmensegratitudeandacurioushumility.”3診斷“瀕死”的障礙

BarrierstoDiagnose“DYING”對病人可能會好轉的期待不能明確地診斷對病人狀況的分歧不能識別關鍵的癥狀和體征不知怎樣對瀕死病人用藥HopethatthepatientmaygetbetterNodefinitediagnosisDisagreementaboutthepatient’sconditionFailuretorecognizekeysymptomsandsignsFailuretoknowhowtoprescribeforthedyingpatient不能很好地與病人及其家屬交流維持還是撤除治療的考慮對生存期縮短的恐懼文化和宗教的障礙醫(yī)學-法律的思考PoorabilitytocommunicatewiththefamilyandpatientConcernsaboutwithholdingorwithdrawingtreatmentsFearofforeshorteninglifeCulturalandspiritualbarriersMedico-legalconcernsEllershaw,Ward.BMJ;1/4/034瀕死過程的生理學變化

Physiologicchangesduringthedyingprocess進行性增加的無力和疲乏Increasingweakness,fatigue進行性減少的食欲/水攝入Decreasingappetite/fluidintake進行性降低的血液灌注Decreasingbloodperfusion閉眼功能的喪失Lossofabilitytocloseeyes神經(jīng)性功能障礙Neurologicdysfunction疼痛Pain6無力/疲乏

Weakness/fatigue運動能力減弱Decreasedabilitytomove關節(jié)部位乏力Jointpositionfatigue褥瘡的危險性增加Increasedriskofpressureulcers姑息關懷的需求增加Increasedneedforcare日常生活的行為activitiesofdailyliving翻身，運動，按摩turning,movement,massage7進行性減少的食欲/食物攝入

Decreasingappetite/foodintake恐懼：“屈服”與饑餓Fears:“givingin”andstarvation提示Reminders食物可致嘔吐foodmaybenauseating厭食可起保護作用anorexiamaybeprotective吸入的危險riskofaspiration銼牙以表達食欲與控制clenchedteethexpressdesires,ontrol幫助家屬找出照護的替代方法

Helpfamilyfindalternativewaystocare8進行性減少的液體攝入……

Decreasingfluidintake...口服補充液體恐懼：脫水，口渴=痛苦提醒家屬及照護者脫水不會引起痛苦脫水可能是一種保護口渴可以通過良好的口腔護理得以治療OralrehydratingfluidsFears:dehydration,thirst=sufferingRemindfamilies,caregiversdehydrationdoesnotcausedistressdehydrationmaybeprotectiveThirstcanbetreatedbygoodmouthcare9進行性減少的液體攝入

Decreasingfluidintake胃腸外補液可能是有害的液體負荷過大，呼吸困難，咳嗽，分泌增加全身性水腫粘膜/結膜的護理Parenteralfluidsmaybeharmfulfluidoverload,breathlessness,cough,secretionsanasarcaMucosa/conjunctivacare10進行性減少的血液灌注

Decreasingbloodperfusion心動過速，低血壓外周厥冷，發(fā)紺皮膚斑點狀陰影尿量減少胃腸外的液體不回流Tachycardia,hypotensionPeripheralcooling,cyanosisMottlingofskinDiminishedurineoutputParenteralfluidswillnotreverse11神經(jīng)功能障礙

Neurologicdysfunction意識進行性的降低與無意識的病人的交流終末期譫妄呼吸的變化吞咽能力喪失，括約肌失控DecreasinglevelofconsciousnessCommunicationwiththeunconsciouspatientTerminaldeliriumChangesinrespirationLossofabilitytoswallow,sphinctercontrol12死亡的兩條途徑

2roadstodeath煩躁不安Restless精神錯亂Confused幻覺Hallucinations麻木性譫妄Mumbling

Delirium肌陣攣MyoclonicJerks倦睡Sleepy疲乏Lethargic反應遲鈍Obtunded半昏迷狀態(tài)Semicomatose昏迷狀態(tài)Comatose

抽搐Seizures通常的途徑THEUSUALROAD痛苦的途徑THEDIFFICULTROAD正常Normal死亡Dead震顫Tremulous13進行性減弱的意識

Decreasinglevelofconsciousness“死亡的通常途徑”“Theusualroadtodeath”死亡進展Progression睫毛反射Eyelashreflex14與無意識的病人交流……

Communicationwiththeunconsciouspatient...對親屬造成痛苦意識能力＞反應能力假定病人能夠聽懂每一句話DistressingtofamilyAwareness>abilitytorespondAssumepatienthearseverything15與無意識的病人交流

Communicationwiththeunconsciouspatient創(chuàng)造熟悉的環(huán)境在交流中應包含確保有人在場與安全允許死亡接觸CreatefamiliarenvironmentIncludeinconversationsassureofpresence,safetyGivepermissiontodieTouch16終末期譫妄

Terminaldelirium“死亡的痛苦之路”“Thedifficultroadtodeath”臨床處理Medicalmanagement停止刺激劑discontinueoffendingagents適當?shù)剡M行水化作用？gentlehydration?苯二氮卓類benzodiazepines勞拉西泮,咪達唑侖lorazepam,midazolam神經(jīng)安定藥物neuroleptics氟哌啶醇，氯丙嗪haloperidol,chlorpromazine抽搐（癲癇發(fā)作）Seizures家屬需要支持與教育Familyneedssupport,education17呼吸的變化……

Changesinrespiration...呼吸模式的改變進行性減少的潮氣量呼吸暫停切尼·斯鐸克斯氏呼吸應用輔助肌末期反射性呼吸AlteredbreathingpatternsdiminishingtidalvolumeapneaCheyne-Stokesrespirationsaccessorymuscleuselastreflexbreaths18呼吸的變化

Changesinrespiration

恐懼窒息處理親屬支持氧氣可延長瀕死過程呼吸困難FearssuffocationManagementfamilysupportoxygenmayprolongdyingprocessbreathlessness19吞咽能力的喪失

Lossofabilitytoswallow嘔吐反射的喪失唾液與分泌液的蓄積使用東莨菪堿以減少分泌液體位引流特殊體位吸痰LossofgagreflexBuildupofsaliva,secretionsscopolaminetodrysecretionsposturaldrainagepositioningsuctioning20括約肌失控

Lossofsphinctercontrol大小便失禁家屬需要知識與支持清潔與皮膚護理安置尿管吸收墊，表面清潔Incontinenceofurine,stoolFamilyneedsknowledge,supportCleaning,skincareUrinarycathetersAbsorbentpads,surfaces21疼痛……

Pain...對增加疼痛的恐懼對無意識病人的評估持續(xù)性與短暫性的表現(xiàn)痛苦面容或者體征突發(fā)性疼痛與靜止性疼痛區(qū)別于終末期譫妄FearofincreasedpainAssessmentoftheunconsciouspatientpersistentvsfleetingexpressiongrimaceorphysiologicsignsincidentvsrestpaindistinctionfromterminaldelirium22疼痛

Pain對無尿的處理停止嗎啡的按時劑量和輸注必要時給予突破性劑量(prn)最少侵襲性的給藥途徑Managementwhennourineoutputstoproutinedosing,infusionsofmorphinebreakthroughdosingasneeded(prn)leastinvasiverouteofadministration23閉眼功能喪失

Lossofabilitytocloseeyes眶后脂墊喪失眼瞼長度不足結膜裸露干燥和疼痛的危險增加保持濕潤Lossofretro-orbitalfatpadInsufficienteyelidlengthConjunctivalexposureincreasedriskofdryness,painmaintainmoisture24藥物治療

Medications僅限于基本藥物選擇侵襲性較少的給藥途徑首先考慮頰粘膜或口服給藥，其次考慮直腸極少進行皮下和靜脈輸注給藥幾乎不進行肌內注射LimittoessentialmedicationsChooselessinvasiverouteofadministrationbuccalmucosalororalfirst,thenconsiderrectalsubcutaneous,intravenousrarelyintramuscularalmostnever25最大限度的舒服措施……藥物學的

FullComfortMeasures...Pharmacologic藥物治療Medications疼痛Pain焦慮或煩躁不安Anxietyorrestlessness充血/分泌增加Congestion/secretions給藥途徑Routeofadministration皮下/靜脈輸注Subcutaneous/IV舌下Sublingual直腸Rectal26最大限度的舒服措施……藥物學的

FullComfortMeasures...Pharmacologic鎮(zhèn)痛藥物Analgesics嗎啡，氫嗎啡酮Morphine,hydromorphone地塞米松，酮咯酸Dexamethasone,ketorolac焦慮/末期煩躁不安Anxiety/terminalrestlessness氯羥安定，氟哌啶醇，苯巴比妥Lorazepam,haloperidol,phenobarbital氯丙嗪（靜脈注射或直腸給予）Chlopromazine(IVorPR)27最大限度的舒服措施……藥物學的

FullComfortMeasures...Pharmacologic上呼吸道充血胃長寧，阿托品皮下注射或靜脈注射莨菪堿（舌下），東莨菪堿透皮劑由于呼吸頻率減慢，血壓過低，或由于過度鎮(zhèn)靜，不要給予鎮(zhèn)靜劑或阿片類制劑給藥繼續(xù)給抗驚厥藥UpperairwaycongestionGlycopyrrolate,atropineSCorIVHyoscyamine(SL),scopolaminepatchDonotholdsedativemedicationsoropioidsbecauseoflowrespiratoryrate,lowbloodpressureorsedationContinueanti-convulsant28最大限度的舒服措施……非藥物學的

FullComfortMeasures

...Non-pharmacologic停止常規(guī)醫(yī)囑考慮停止鼻胃管/corpak對呼吸困難者吹風扇最喜愛的音樂或保持安靜定時翻身對精神錯亂者反復定向必要時每兩個小時口腔/眼部護理DCroutineordersConsiderDCNGT/corpakFanonfacefordyspneaFavoritemusicorquietFrequentrepositioningFrequentre-orientation

forconfusionMouth/eyecareevery2hours

asneeded每日床上沐浴和清洗放松技術適當?shù)南拗铺皆L者柔和的光線照明輕輕接觸甚至當病人昏迷時也對病人輕言細語地交談搬走室內不必要的家具DailybedbathandlotionRelaxationtechniquesRestrictvisitorsasappropriateSoftlightingSofttouchSpeaksoftlytopatientevenwhencomatoseRemoveunnecessaryequipmentfromtheroom

29提問……

Ask…我們是否需要——Doweneedto_________?每日四次地檢查血糖?CheckbloodglucoseQID?每班都檢查生命體征?Checkvitalsqshift?每天上午都做實驗室檢查?GetlabsqAM?對病人進行X光檢查?Sendthepatientdownforx-rays?建立另一個靜脈通道?PutinanotherIV?肌內注射給藥?GivemedicationsIM?控制病人飲食?Restricthis/herdiet?我們是否可以皮下注射給藥?Canwegivethismedicationsubcutaneously?30皮下輸注

SubcutaneousInfusion吞咽困難Troubleswallowing需多次注射給藥Needformultipleinjectionsandmedicines在英國，常應用注射驅動器（微泵）InUK,asyringedriveriscommonlyused在美國，應用計算機控制的微泵InUSA,computerizedpumpisused31微泵用藥物

SyringeDriverMedicines常用Common偶爾Occasional不用Never嗎啡

Morphine酮咯酸

Ketoralac丙氯拉嗪Prochlorperazine東莨菪堿

Hyoscine芬太尼

Fentanyl地西泮

Diazepam咪達唑侖

Midazolam氯硝安定

Clonazepam度冷丁/哌替啶Demerol/Pethidine塞克利嗪

Cyclizine甲氧異丁嗪Methotrimeparazine氯丙嗪

Largactil氫化嗎啡酮Hydromorphone苯巴比妥

Phenobarbital胃長寧Glycopyrolate地塞米松

Dexamethasone氟哌啶醇Haloparadol氯胺酮

Ketamine滅吐靈

Metoclopramide奧曲肽

Octreotide32OctMidMeto