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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“死亡的痛苦之路” “The difficult
