1、瀕死的病人生理學的變化癥狀的處理知識目 的Objectives識別、評估、并處理瀕死病人的病學理生理學變化Recognize, assess, and manage the pathophysiologic changes of dying家庭成員的引證Family Members Quote“過去數年的個人經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，而且所有的職業照護者都以專業知識、職業道德、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

2、對這一醫學領域的敬畏。”“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 that everything that could have been done was done, that those who cared did so with knowledge, professionalism, devotion,

3、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.”診斷“瀕死”的障礙Barriers to Diagnose “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Hope that the patient may get betterNo definite diagnosisDi

4、sagreement about the patients conditionFailure to recognize key symptoms and signsFailure to know how to prescribe for the dying patient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學-法律的思考Poor ability to communicate with the family and patientConcerns about withholding or withdrawing treatmentsFear of

5、 foreshortening lifeCultural and spiritual barriersMedico-legal concernsEllershaw, Ward. BMJ; 1/4/03如果不對“瀕死”進行診斷 If Diagnosis of “DYING” is Not Made . . .病人及其家屬不能意識到死亡的逼近病人及其家屬對內科醫生和護士失去信任由于無法控制的癥狀,病人在痛苦和無尊嚴的狀況下死亡Patient and family not aware that death is imminentPatient and family loses trust in th

6、e physician and nursesPatient dies with uncontrolled symptoms leading to a distressing and undignified death病人及其家屬感覺不滿意死亡時心肺功能狀態尚可不能滿足文化和宗教的需求Patient and family feel dissatisfiedCardiopulmonary resuscitation may be initiated at deathCultural and spiritual needs not met瀕死過程的生理學變化Physiologic changes d

7、uring the dying process進行性增加的無力和疲乏 Increasing weakness, fatigue進行性減少的食欲/水攝入 Decreasing appetite / fluid intake進行性降低的血液灌注 Decreasing blood perfusion閉眼功能的喪失 Loss of ability to close eyes神經性功能障礙 Neurologic dysfunction疼痛 Pain無力/疲乏Weakness / fatigue運動能力減弱 Decreased ability to move關節部位乏力 Joint position fa

8、tigue褥瘡的危險性增加 Increased risk of pressure ulcers姑息關懷的需求增加 Increased need for care日常生活的行為 activities of daily living翻身，運動，按摩 turning, movement, massage進行性減少的食欲/食物攝入Decreasing appetite / food intake恐懼：“屈服”與饑餓 Fears: “giving in” and starvation提示Reminders食物可致嘔吐 food may be nauseating厭食可起保護作用 anorexia may

9、 be protective吸入的危險 risk of aspiration銼牙以表達食欲與控制 clenched teeth express desires,ontrol幫助家屬找出照護的替代方法 Help family find alternative ways to care進行性減少的液體攝入 Decreasing fluid intake . . .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Oral rehydrating fluidsFears: dehydration, thirst = sufferin

10、gRemind families, caregiversdehydration does not cause distressdehydration may be protectiveThirst can be treated by good mouth care進行性減少的液體攝入Decreasing fluid intake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Parenteral fluids may be harmfulfluid overload, breathlessness, cough, secretionsanasarcaMuc

11、osa / conjunctiva care進行性減少的血液灌注Decreasing blood perfusion心動過速，低血壓外周厥冷，發紺皮膚斑點狀陰影尿量減少胃腸外的液體不回流Tachycardia, hypotensionPeripheral cooling, cyanosisMottling of skinDiminished urine outputParenteral fluids will not reverse神經功能障礙Neurologic dysfunction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Decreasing lev

12、el of consciousnessCommunication with the unconscious patientTerminal deliriumChanges in respirationLoss of ability to swallow, sphincter control死亡的兩條途徑2 roads to death煩躁不安Restless精神錯亂Confused幻覺Hallucinations麻木性譫妄Mumbling Delirium肌陣攣Myoclonic Jerks倦睡Sleepy疲乏Lethargic反應遲鈍Obtunded半昏迷狀態Semicomatose昏迷狀態

13、Comatose 抽搐Seizures通常的途徑THE USUAL ROAD痛苦的途徑THE DIFFICULT ROAD正常Normal死亡Dead震顫Tremulous進行性減弱的意識Decreasing level of consciousness“死亡的通常途徑” “The usual road to death”死亡進展 Progression睫毛反射 Eyelash reflex與無意識的病人交流 Communication with the unconscious patient . . .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Distressing to fam

14、ilyAwareness ability to respondAssume patient hears everything與無意識的病人交流 Communication with the unconscious patient創造熟悉的環境在交流中應包含確保有人在場與安全允許死亡接觸Create familiar environmentInclude in conversationsassure of presence, safetyGive permission to dieTouch 終末期譫妄Terminal delirium“死亡的痛苦之路” “The difficult road

15、to death”臨床處理 Medical management停止刺激劑 discontinue offending agents適當地進行水化作用？ gentle hydration?苯二氮卓類 benzodiazepines勞拉西泮, 咪達唑侖 lorazepam, midazolam 神經安定藥物 neuroleptics氟哌啶醇，氯丙嗪 haloperidol, chlorpromazine抽搐（癲癇發作） Seizures家屬需要支持與教育 Family needs support, education呼吸的變化 Changes in respiration . . .呼吸模式的改

16、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Altered breathing patternsdiminishing tidal volumeapneaCheyne-Stokes respirationsaccessory muscle uselast reflex breaths呼吸的變化Changes in respiration 恐懼窒息處理親屬支持氧氣可延長瀕死過程呼吸困難FearssuffocationManagementfamily supportoxygen may prolong dying processbreathlessness吞咽能力的喪失L

17、oss of ability to swallow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Loss of gag reflexBuildup of saliva, secretionsscopolamine to dry secretionspostural drainagepositioningsuctioning括約肌失控Loss of sphincter control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Incontinence of urine, stoolFamily needs knowledge, support

18、Cleaning, skin careUrinary cathetersAbsorbent pads, surfaces疼痛 Pain . . .對增加疼痛的恐懼對無意識病人的評估持續性與短暫性的表現痛苦面容或者體征突發性疼痛與靜止性疼痛區別于終末期譫妄Fear of increased painAssessment of the unconscious patientpersistent vs fleeting expressiongrimace or physiologic signsincident vs rest paindistinction from terminal deliri

19、um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Management when no urine outputstop routine dosing, infusions of morphinebreakthrough dosing as needed (prn)least invasive route of administration閉眼功能喪失Loss of ability to close eyes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Loss of retro-orbital fat padInsuffic

20、ient eyelid lengthConjunctival exposureincreased risk of dryness, painmaintain moisture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Limit to essential medicationsChoose less invasive route of administrationbuccal mucosal or oral first, then consider rectalsubcutaneous,

21、intravenous rarelyintramuscular almost never最大限度的舒服措施藥物學的Full Comfort Measures . . . Pharmacologic藥物治療 Medications疼痛 Pain焦慮或煩躁不安 Anxiety or restlessness充血/分泌增加 Congestion / secretions給藥途徑 Route of administration皮下/靜脈輸注 Subcutaneous/IV舌下 Sublingual直腸 Rectal最大限度的舒服措施藥物學的Full Comfort Measures . . . Pha

22、rmacologic鎮痛藥物 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 / terminal restlessness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 (IV or PR)最大限度的舒服措施藥物學的Full Comfort Measures . . . Pharmacologic上呼吸道充血胃長寧，阿托品 皮下注射 或靜脈注射莨

23、菪堿（舌下），東莨菪堿透皮劑由于呼吸頻率減慢，血壓過低，或由于過度鎮靜，不要給予鎮靜劑或阿片類制劑給藥繼續給抗驚厥藥Upper airway congestionGlycopyrrolate, atropine SC or IVHyoscyamine (SL), scopolamine patchDo not hold sedative medications or opioids because of low respiratory rate, low blood pressure or sedationContinue anti-convulsant最大限度的舒服措施非藥物學的Full C

24、omfort Measures . . . Non-pharmacologic停止常規醫囑考慮停止鼻胃管/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DC routine ordersConsider DC NGT/corpakFan on face 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

25、松技術適當的限制探訪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Daily bed bath and lotionRelaxation techniquesRestrict visitors as appropriateSoft lightingSoft touch Speak softly to patient even when comatoseRemove unnecessary equipment from the room提問 Ask我們是否需要Do we need to _?每日四次地檢查血糖? Check blood glucose QID?

26、每班都檢查生命體征? Check vitals q shift?每天上午都做實驗室檢查? Get labs q AM?對病人進行X光檢查? Send the patient down for x-rays?建立另一個靜脈通道? Put in another IV?肌內注射給藥? Give medications IM?控制病人飲食? Restrict his/her diet?我們是否可以皮下注射給藥? Can we give this medication subcutaneously?皮下輸注Subcutaneous Infusion吞咽困難 Trouble swallowing需多次注射

27、給藥 Need for multiple injections and medicines在英國，常應用注射驅動器（微泵） In UK, a syringe driver is commonly used在美國，應用計算機控制的微泵 In USA, computerized pump is used微泵用藥物Syringe Driver Medicines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 OctreotideOctMidMetoMethKetHBrHaldGlycMorpDexCyclHBBrIncompatib