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1、1,濒死的病人The Dying Patient,Terence L.Gutgsell,MDHospice of the BluegrassLexington,Kentucky,生理学的变化症状的处理Physiologic ChangesSymptom Management,2,目 的Objectives,识别、评估、并处理濒死病人的病学理生理学变化Recognize,assess,and manage the pathophysiologic changes of dying,3,家庭成员的引证Family Members Quote,“过去数年的个人经历使我明白了一个人的最后几天会在人的记
2、忆中留下永久的烙印。失去所带来的痛苦依然是很强烈的，但是当感受到所有可以做的都做了，而且所有的职业照护者都以专业知识、职业道德、奉献精神和爱心对病人给予了姑息关怀，让患者能够在他们所深爱的人的关怀下没有痛苦地和舒服地死亡，我们心中就充满了无限的感激和对这一医学领域的敬畏。”“My personal experience of the past few years has taught me that those last few days color ones memories permanently.The pain of loss is still immense,but to feel
3、that everything that could have been done was done,that those who cared did so with knowledge,professionalism,devotion,and even love,and that the person died without pain,comfortably,with those they loved around them,is to feel immense gratitude and a curious humility.”,4,诊断“濒死”的障碍Barriers to Diagno
4、se“DYING”,对病人可能会好转的期待不能明确地诊断对病人状况的分歧不能识别关键的症状和体征不知怎样对濒死病人用药Hope that the patient may get betterNo definite diagnosisDisagreement about the patients conditionFailure to recognize key symptoms and signsFailure to know how to prescribe for the dying patient,不能很好地与病人及其家属交流维持还是撤除治疗的考虑对生存期缩短的恐惧文化和宗教的障碍医学-
5、法律的思考Poor ability to communicate with the family and patientConcerns about withholding or withdrawing treatmentsFear of foreshortening lifeCultural and spiritual barriersMedico-legal concerns,Ellershaw,Ward.BMJ;1/4/03,5,如果不对“濒死”进行诊断 If Diagnosis of“DYING”is Not Made.,病人及其家属不能意识到死亡的逼近病人及其家属对内科医生和护士失去
6、信任由于无法控制的症状,病人在痛苦和无尊严的状况下死亡Patient and family not aware that death is imminentPatient and family loses trust in the physician and nursesPatient dies with uncontrolled symptoms leading to a distressing and undignified death,病人及其家属感觉不满意死亡时心肺功能状态尚可不能满足文化和宗教的需求Patient and family feel dissatisfiedCardiop
7、ulmonary resuscitation may be initiated at deathCultural and spiritual needs not met,6,濒死过程的生理学变化Physiologic changes during the dying process,进行性增加的无力和疲乏 Increasing weakness,fatigue进行性减少的食欲/水摄入 Decreasing appetite/fluid intake进行性降低的血液灌注 Decreasing blood perfusion闭眼功能的丧失 Loss of ability to close eyes
8、神经性功能障碍 Neurologic dysfunction疼痛 Pain,7,无力/疲乏Weakness/fatigue,运动能力减弱 Decreased ability to move关节部位乏力 Joint position fatigue褥疮的危险性增加 Increased risk of pressure ulcers姑息关怀的需求增加 Increased need for care日常生活的行为 activities of daily living翻身，运动，按摩 turning,movement,massage,8,进行性减少的食欲/食物摄入Decreasing appetite
9、/food intake,恐惧：“屈服”与饥饿 Fears:“giving in”and starvation提示Reminders食物可致呕吐 food may be nauseating厌食可起保护作用 anorexia may be protective吸入的危险 risk of aspiration锉牙以表达食欲与控制 clenched teeth express desires,ontrol帮助家属找出照护的替代方法 Help family find alternative ways to care,9,进行性减少的液体摄入 Decreasing fluid intake.,口服补充
10、液体恐惧：脱水，口渴=痛苦提醒家属及照护者脱水不会引起痛苦脱水可能是一种保护口渴可以通过良好的口腔护理得以治疗Oral rehydrating fluidsFears:dehydration,thirst=sufferingRemind families,caregiversdehydration does not cause distressdehydration may be protectiveThirst can be treated by good mouth care,10,进行性减少的液体摄入Decreasing fluid intake,胃肠外补液可能是有害的液体负荷过大，呼吸
11、困难，咳嗽，分泌增加全身性水肿粘膜/结膜的护理Parenteral fluids may be harmfulfluid overload,breathlessness,cough,secretionsanasarcaMucosa/conjunctiva care,11,进行性减少的血液灌注Decreasing blood perfusion,心动过速，低血压外周厥冷，发绀皮肤斑点状阴影尿量减少胃肠外的液体不回流Tachycardia,hypotensionPeripheral cooling,cyanosisMottling of skinDiminished urine outputPar
12、enteral fluids will not reverse,12,神经功能障碍Neurologic dysfunction,意识进行性的降低与无意识的病人的交流终末期谵妄呼吸的变化吞咽能力丧失，括约肌失控Decreasing level of consciousnessCommunication with the unconscious patientTerminal deliriumChanges in respirationLoss of ability to swallow,sphincter control,13,死亡的两条途径2 roads to death,烦躁不安Restle
13、ss,精神错乱Confused,幻觉Hallucinations,麻木性谵妄Mumbling Delirium,肌阵挛Myoclonic Jerks,倦睡Sleepy,疲乏Lethargic,反应迟钝Obtunded,半昏迷状态Semicomatose,昏迷状态Comatose,抽搐Seizures,通常的途径THE USUAL ROAD,痛苦的途径THE DIFFICULT ROAD,正常Normal,死亡Dead,震颤Tremulous,14,进行性减弱的意识Decreasing level of consciousness,“死亡的通常途径”“The usual road to deat
14、h”死亡进展 Progression睫毛反射 Eyelash reflex,15,与无意识的病人交流 Communication with the unconscious patient.,对亲属造成痛苦意识能力反应能力假定病人能够听懂每一句话Distressing to familyAwareness ability to respondAssume patient hears everything,16,与无意识的病人交流 Communication with the unconscious patient,创造熟悉的环境在交流中应包含确保有人在场与安全允许死亡接触Create famil
15、iar environmentInclude in conversationsassure of presence,safetyGive permission to dieTouch,17,终末期谵妄Terminal delirium,“死亡的痛苦之路”“The difficult road to death”临床处理 Medical management停止刺激剂 discontinue offending agents适当地进行水化作用？gentle hydration?苯二氮卓类 benzodiazepines劳拉西泮,咪达唑仑 lorazepam,midazolam 神经安定药物 ne
16、uroleptics氟哌啶醇，氯丙嗪 haloperidol,chlorpromazine抽搐（癫痫发作）Seizures家属需要支持与教育 Family needs support,education,18,呼吸的变化 Changes in respiration.,呼吸模式的改变进行性减少的潮气量呼吸暂停切尼斯铎克斯氏呼吸应用辅助肌末期反射性呼吸Altered breathing patternsdiminishing tidal volumeapneaCheyne-Stokes respirationsaccessory muscle uselast reflex breaths,19,
17、呼吸的变化Changes in respiration,恐惧窒息处理亲属支持氧气可延长濒死过程呼吸困难FearssuffocationManagementfamily supportoxygen may prolong dying processbreathlessness,20,吞咽能力的丧失Loss of ability to swallow,呕吐反射的丧失唾液与分泌液的蓄积使用东莨菪碱以减少分泌液 体位引流特殊体位吸痰Loss of gag reflexBuildup of saliva,secretionsscopolamine to dry secretionspostural dr
18、ainagepositioningsuctioning,21,括约肌失控Loss of sphincter control,大小便失禁家属需要知识与支持清洁与皮肤护理安置尿管吸收垫，表面清洁Incontinence of urine,stoolFamily needs knowledge,supportCleaning,skin careUrinary cathetersAbsorbent pads,surfaces,22,疼痛 Pain.,对增加疼痛的恐惧对无意识病人的评估持续性与短暂性的表现痛苦面容或者体征突发性疼痛与静止性疼痛区别于终末期谵妄Fear of increased painA
19、ssessment of the unconscious patientpersistent vs fleeting expressiongrimace or physiologic signsincident vs rest paindistinction from terminal delirium,23,疼 痛Pain,对无尿的处理停止吗啡的按时剂量和输注必要时给予突破性剂量(prn)最少侵袭性的给药途径Management when no urine outputstop routine dosing,infusions of morphinebreakthrough dosing a
20、s needed(prn)least invasive route of administration,24,闭眼功能丧失Loss of ability to close eyes,眶后脂垫丧失眼睑长度不足结膜裸露干燥和疼痛的危险增加保持湿润Loss of retro-orbital fat padInsufficient eyelid lengthConjunctival exposureincreased risk of dryness,painmaintain moisture,25,药物治疗Medications,仅限于基本药物选择侵袭性较少的给药途径首先考虑颊粘膜或口服给药，其次考虑
21、直肠极少进行皮下和静脉输注给药几乎不进行肌内注射Limit to essential medicationsChoose less invasive route of administrationbuccal mucosal or oral first,then consider rectalsubcutaneous,intravenous rarelyintramuscular almost never,26,最大限度的舒服措施药物学的Full Comfort Measures.Pharmacologic,药物治疗 Medications疼痛 Pain焦虑或烦躁不安 Anxiety or r
22、estlessness充血/分泌增加 Congestion/secretions给药途径 Route of administration皮下/静脉输注 Subcutaneous/IV舌下 Sublingual直肠 Rectal,27,最大限度的舒服措施药物学的Full Comfort Measures.Pharmacologic,镇痛药物 Analgesics吗啡，氢吗啡酮 Morphine,hydromorphone地塞米松，酮咯酸 Dexamethasone,ketorolac焦虑/末期烦躁不安 Anxiety/terminal restlessness氯羟安定，氟哌啶醇，苯巴比妥 Lor
23、azepam,haloperidol,phenobarbital氯丙嗪（静脉注射或直肠给予）Chlopromazine(IV or PR),28,最大限度的舒服措施药物学的Full Comfort Measures.Pharmacologic,上呼吸道充血胃长宁，阿托品 皮下注射 或静脉注射莨菪碱（舌下），东莨菪碱透皮剂由于呼吸频率减慢，血压过低，或由于过度镇静，不要给予镇静剂或阿片类制剂给药继续给抗惊厥药Upper airway congestionGlycopyrrolate,atropine SC or IVHyoscyamine(SL),scopolamine patchDo not
24、hold sedative medications or opioids because of low respiratory rate,low blood pressure or sedationContinue anti-convulsant,29,最大限度的舒服措施非药物学的Full Comfort Measures.Non-pharmacologic,停止常规医嘱考虑停止鼻胃管/corpak对呼吸困难者吹风扇最喜爱的音乐或保持安静定时翻身对精神错乱者反复定向必要时每两个小时口腔/眼部护理DC routine ordersConsider DC NGT/corpakFan on face
25、 for dyspneaFavorite music or quietFrequent repositioningFrequent re-orientation for confusionMouth/eye care every 2 hours as needed,每日床上沐浴和清洗放松技术适当的限制探访者柔和的光线照明轻轻接触甚至当病人昏迷时也对病人轻言细语地交谈搬走室内不必要的家具Daily bed bath and lotionRelaxation techniquesRestrict visitors as appropriateSoft lightingSoft touch Spea
26、k softly to patient even when comatoseRemove unnecessary equipment from the room,30,提问 Ask,我们是否需要Do we need to _?每日四次地检查血糖?Check blood glucose QID?每班都检查生命体征?Check vitals q shift?每天上午都做实验室检查?Get labs q AM?对病人进行X光检查?Send the patient down for x-rays?建立另一个静脉通道?Put in another IV?肌内注射给药?Give medications I
27、M?控制病人饮食?Restrict his/her diet?我们是否可以皮下注射给药?Can we give this medication subcutaneously?,31,皮下输注Subcutaneous Infusion,吞咽困难 Trouble swallowing需多次注射给药 Need for multiple injections and medicines在英国，常应用注射驱动器（微泵）In UK,a syringe driver is commonly used在美国，应用计算机控制的微泵 In USA,computerized pump is used,32,微泵用药
28、物Syringe Driver Medicines,33,Incompatible,Sometimes incompatible,Compatible,No data available,34,急症Emergencies,状况Situations颈动脉破裂或大出血Ruptured carotid or massive hemorrhage严重呼吸困难Severe respiratory distress药物治疗Medications吗啡 10mg，静脉注射/Morphine 10mg IV/SQ劳拉西泮 2mg，静脉注射/Lorazepam 2mg IV/SQ如果不是阿片类药物初用者，则需要给
29、予高剂量药物Higher doses needed if not opioid-nave,35,家属引证Family Members Quote,“我在过去几年中的个人经历使我明白了一个人的最后几天会在人的记忆中留下永久的烙印。丧失亲人的痛苦依然是很强烈的，但是当感受到一切可以做的都做了，所有关怀病人的人都以专业知识，专业技能，奉献精神，和爱心对病人给予了关怀，并且病人能够在他们所深爱的人的关注下毫无疼痛地安乐地去世，我们心中就充满了无尽的感激和对这一医学领域的敬畏。”“My personal experience of the past few years has taught me tha
30、t those last few days color ones memories permanently.The pain of loss is still immense,but to feel that everything that could have been done was done,that those who cared did so with knowledge,professionalism,devotion,and even love,and that the person died without pain,comfortably,with those they loved around them,is to feel immense gratitude and a curious humility.”,36,
