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1、濒死的病人 The Dying Patient Terence L. Terence L. GutgsellGutgsell, MD, MD Hospice of the BluegrassHospice of the Bluegrass Lexington, KentuckyLexington, Kentucky 生理学的变化 症状的处理 Physiologic Changes Symptom Management 目 的 Objectives l识别、评估、并处理濒死病人的病学理生理学变化 lRecognize, assess, and manage the pathophysiologi
2、c changes of dying 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 da
3、ys 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 aroun
4、d them, is to feel immense gratitude and a curious humility.” 诊断“濒死”的障碍 Barriers to Diagnose “DYING” l对病人可能会好转的期待 l不能明确地诊断 l对病人状况的分歧 l不能识别关键的症状和体征 l不知怎样对濒死病人用药 lHope that the patient may get better lNo definite diagnosis lDisagreement about the patients condition lFailure to recognize key symptoms a
5、nd signs lFailure to know how to prescribe for the dying patient l不能很好地与病人及其家属交流 l维持还是撤除治疗的考虑 l对生存期缩短的恐惧 l文化和宗教的障碍 l医学-法律的思考 lPoor ability to communicate with the family and patient lConcerns about withholding or withdrawing treatments lFear of foreshortening life lCultural and spiritual barriers lM
6、edico-legal concerns Ellershaw, Ward. BMJ; 1/4/03 如果不对“濒死”进行诊断 If Diagnosis of “DYING” is Not Made . . . l病人及其家属不能意识到死亡的 逼近 l病人及其家属对内科医生和护士 失去信任 l由于无法控制的症状,病人在痛 苦和无尊严的状况下死亡 lPatient and family not aware that death is imminent lPatient and family loses trust in the physician and nurses lPatient dies
7、with uncontrolled symptoms leading to a distressing and undignified death l病人及其家属感觉不满意 l死亡时心肺功能状态尚可 l不能满足文化和宗教的需求 lPatient and family feel dissatisfied lCardiopulmonary resuscitation may be initiated at death lCultural and spiritual needs not met 濒死过程的生理学变化 Physiologic changes during the dying proce
8、ss l进行性增加的无力和疲乏 Increasing weakness, fatigue l进行性减少的食欲/水摄入 Decreasing appetite / fluid intake l进行性降低的血液灌注 Decreasing blood perfusion l闭眼功能的丧失 Loss of ability to close eyes l神经性功能障碍 Neurologic dysfunction l疼痛 Pain 无力/疲乏 Weakness / fatigue l运动能力减弱 Decreased ability to move l关节部位乏力 Joint position fatig
9、ue l褥疮的危险性增加 Increased risk of pressure ulcers l姑息关怀的需求增加 Increased need for care l日常生活的行为 activities of daily living l翻身，运动，按摩 turning, movement, massage 进行性减少的食欲/食物摄入 Decreasing appetite / food intake l恐惧：“屈服”与饥饿 Fears: “giving in” and starvation l提示Reminders 食物可致呕吐 food may be nauseating 厌食可起保护作用
10、 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 l帮助家属找出照护的替代方法 Help family find alternative ways to care 进行性减少的液体摄入 Decreasing fluid intake . . . l口服补充液体 l恐惧：脱水，口渴=痛苦 l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 lOral rehydrating fluids lFears:
11、 dehydration, thirst = suffering lRemind families, caregivers dehydration does not cause distress dehydration may be protective Thirst can be treated by good mouth care 进行性减少的液体摄入 Decreasing fluid intake l胃肠外补液可能是有害的 液体负荷过大，呼吸困难，咳嗽，分泌增加 全身性水肿 l粘膜/结膜的护理 lParenteral fluids may be harmful fluid overloa
12、d, breathlessness, cough, secretions anasarca lMucosa / conjunctiva care 进行性减少的血液灌注 Decreasing blood perfusion l心动过速，低血压 l外周厥冷，发绀 l皮肤斑点状阴影 l尿量减少 l胃肠外的液体不回流 lTachycardia, hypotension lPeripheral cooling, cyanosis lMottling of skin lDiminished urine output lParenteral fluids will not reverse 神经功能障碍 Ne
13、urologic dysfunction l意识进行性的降低 l与无意识的病人的交流 l终末期谵妄 l呼吸的变化 l吞咽能力丧失，括约肌失控 lDecreasing level of consciousness lCommunication with the unconscious patient lTerminal delirium lChanges in respiration lLoss of ability to swallow, sphincter control 死亡的两条途径 2 roads to death 烦躁不安烦躁不安 RestlessRestless 精神错乱精神错乱
14、ConfusedConfused 幻觉幻觉HallucinationsHallucinations 麻木性谵妄麻木性谵妄 MumblingMumbling DeliriumDelirium 肌阵挛肌阵挛 MyoclonicMyoclonic Jerks Jerks 倦睡倦睡SleepySleepy 疲乏疲乏LethargicLethargic 反应迟钝反应迟钝ObtundedObtunded 半昏迷状态半昏迷状态SemicomatoseSemicomatose 昏迷状态昏迷状态ComatoseComatose 抽搐抽搐SeizuresSeizures 通常的途径 THE USUAL ROAD
15、痛苦的途径 THE DIFFICULT ROAD 正常 Normal 死亡 Dead 震颤震颤 TremulousTremulous 进行性减弱的意识 Decreasing level of consciousness l“死亡的通常途径” “The usual road to death” l死亡进展 Progression l睫毛反射 Eyelash reflex 与无意识的病人交流 Communication with the unconscious patient . . . l对亲属造成痛苦 l意识能力反应能力 l假定病人能够听懂每一句话 lDistressing to family
16、 lAwareness ability to respond lAssume patient hears everything 与无意识的病人交流 Communication with the unconscious patient l创造熟悉的环境 l在交流中应包含 确保有人在场与安全 l允许死亡 l接触 lCreate familiar environment lInclude in conversations assure of presence, safety lGive permission to die lTouch 终末期谵妄 Terminal delirium l“死亡的痛苦之
17、路” “The difficult road to death” l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 neuroleptics 氟哌啶醇，氯丙嗪 haloperidol, chlorpromazine l抽搐（癫痫发作） Seizures l家属需要支持与教育 Family needs support, education 呼吸的变化
18、 Changes in respiration . . . l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 lAltered breathing patterns diminishing tidal volume apnea Cheyne-Stokes respirations accessory muscle use last reflex breaths 呼吸的变化 Changes in respiration l恐惧 窒息 l处理 亲属支持 氧气可延长濒死过程 呼吸困难 lFears suffocation lManagement fami
19、ly support oxygen may prolong dying process breathlessness 吞咽能力的丧失 Loss of ability to swallow l呕吐反射的丧失 l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 lLoss of gag reflex lBuildup of saliva, secretions scopolamine to dry secretions postural drainage positioning suctioning 括约肌失控 Loss of sphincter control l大小便失禁
20、 l家属需要知识与支持 l清洁与皮肤护理 l安置尿管 l吸收垫，表面清洁 lIncontinence of urine, stool lFamily needs knowledge, support lCleaning, skin care lUrinary catheters lAbsorbent pads, surfaces 疼痛 Pain . . . l对增加疼痛的恐惧 l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 lFear of increased pain lAssessment of the unconscious pat
21、ient persistent vs fleeting expression grimace or physiologic signs incident vs rest pain distinction from terminal delirium 疼 痛 Pain l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 lManagement when no urine output stop routine dosing, infusions of morphine breakthrough dosing as needed (prn) least
22、invasive route of administration 闭眼功能丧失 Loss of ability to close eyes l眶后脂垫丧失 l眼睑长度不足 l结膜裸露 干燥和疼痛的危险增加 保持湿润 lLoss of retro-orbital fat pad lInsufficient eyelid length lConjunctival exposure increased risk of dryness, pain maintain moisture 药物治疗 Medications l仅限于基本药物 l选择侵袭性较少的给药途径 首先考虑颊粘膜或口服给药，其次考虑直肠
23、极少进行皮下和静脉输注给药 几乎不进行肌内注射 lLimit to essential medications lChoose less invasive route of administration buccal mucosal or oral first, then consider rectal subcutaneous, intravenous rarely intramuscular almost never 最大限度的舒服措施药物学的 Full Comfort Measures . . . Pharmacologic l药物治疗 Medications l疼痛 Pain 焦虑或烦
24、躁不安 Anxiety or restlessness 充血/分泌增加 Congestion / secretions l给药途径 Route of administration l皮下/静脉输注 Subcutaneous/IV l舌下 Sublingual 直肠 Rectal 最大限度的舒服措施药物学的 Full Comfort Measures . . . Pharmacologic l镇痛药物 Analgesics l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 /
25、terminal restlessness l氯羟安定，氟哌啶醇，苯巴比妥 Lorazepam, haloperidol, phenobarbital 氯丙嗪（静脉注射或直肠给予） Chlopromazine (IV or PR) 最大限度的舒服措施药物学的 Full Comfort Measures . . . Pharmacologic l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 l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 l继续给抗惊厥药 lUpper airway congestion Glycopyrrol
26、ate, atropine SC or IV Hyoscyamine (SL), scopolamine patch lDo not hold sedative medications or opioids because of low respiratory rate, low blood pressure or sedation lContinue anti-convulsant 最大限度的舒服措施非药物学的 Full Comfort Measures . . . Non-pharmacologic l停止常规医嘱 l考虑停止鼻胃管/corpak l对呼吸困难者吹风扇 l最喜爱的音乐或保持
27、安静 l定时翻身 l对精神错乱者反复定向 l必要时每两个小时口腔/眼部护理 lDC routine orders lConsider DC NGT/corpak lFan on face for dyspnea lFavorite music or quiet lFrequent repositioning lFrequent re-orientation for confusion lMouth/eye care every 2 hours as needed l每日床上沐浴和清洗 l放松技术 l适当的限制探访者 l柔和的光线照明 l轻轻接触 l甚至当病人昏迷时也对病人轻言细语地交谈 l搬走
28、室内不必要的家具 lDaily bed bath and lotion lRelaxation techniques lRestrict visitors as appropriate lSoft lighting lSoft touch lSpeak softly to patient even when comatose lRemove unnecessary equipment from the room 提问 Ask l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
29、 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 IM? 控制病人饮食? Restrict his/her diet? l我们是否可以皮下注射给药? Can we give this medication subcutaneously? 皮下输注 Subcutaneous Infusion l吞咽困难 Trouble swallowing l需多次注射给药 Need for
30、multiple injections and medicines l在英国，常应用注射驱动器（微泵） In UK, a syringe driver is commonly used l在美国，应用计算机控制的微泵 In USA, computerized pump is used 微泵用药物 Syringe Driver Medicines 常用常用CommonCommon偶尔偶尔OccasionalOccasional不用不用NeverNever 吗啡 Morphine酮咯酸 Ketoralac 丙氯拉嗪 Prochlorperazine 东莨菪碱 Hyoscine芬太尼 Fentany
31、l地西泮 Diazepam 咪达唑仑 Midazolam氯硝安定 Clonazepam 度冷丁/哌替啶 Demerol/Pethidine 塞克利嗪 Cyclizine 甲氧异丁嗪 Methotrimeparazine 氯丙嗪 Largactil 氢化吗啡酮 Hydromorphone 苯巴比妥 Phenobarbital 胃长宁 Glycopyrolate 地塞米松 Dexamethasone 氟哌啶醇 Haloparadol氯胺酮 Ketamine 灭吐灵 Metoclopramide 奥曲肽 Octreotide Oct Mid Meto Meth Ket HBr Hald Glyc M
32、orp Dex Cycl HBBr Incompatible Sometimes incompatible Compatible No data available 急症 Emergencies l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 l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，则需要给予高剂
33、量药物 Higher doses needed if not opioid-nave 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 t
34、hat 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.”