濒死的病人课件

1,濒死的病人 The Dying Patient,Terence L. Gutgsell, MD Hospice of the Bluegrass Lexington, Kentucky,生理学的变化 症状的处理 Physiologic Changes Symptom 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 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 Diagnose “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 better No definite diagnosis Disagreement about the patients condition Failure to recognize key symptoms and signs Failure 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-法律的思考 Poor ability to communicate with the family and patient Concerns about withholding or withdrawing treatments Fear of foreshortening life Cultural and spiritual barriers Medico-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 imminent Patient and family loses trust in the physician and nurses Patient 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 dissatisfied Cardiopulmonary resuscitation may be initiated at death Cultural 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 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 / 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 fluids Fears: dehydration, thirst = suffering Remind families, caregivers dehydration does not cause distress dehydration may be protective Thirst 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，呼吸困难，咳嗽，分泌增加 全身性水肿 粘膜/结膜的护理 Parenteral fluids may be harmful fluid overload, breathlessness, cough, secretions anasarca Mucosa / 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, hypotension Peripheral cooling, cyanosis Mottling of skin Diminished urine output Parenteral 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 consciousness Communication with the unconscious patient Terminal delirium Changes in respiration Loss of ability to swallow, sphincter control,13,死亡的两条途径 2 roads to death,烦躁不安 Restless,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 death” 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 family Awareness ability to respond Assume 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 familiar environment Include in conversations assure of presence, safety Give permission to die Touch,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 neuroleptics 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 patterns diminishing tidal volume apnea Cheyne-Stokes respirations accessory muscle use last reflex breaths,19,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 Fears suffocation Management family support oxygen may prolong dying process breathlessness,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 reflex Buildup of saliva, secretions scopolamine to dry secretions postural drainage positioning suctioning,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, stool Family needs knowledge, support Cleaning, skin care Urinary catheters Absorbent 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 pain Assessment of the unconscious patient persistent vs fleeting expression grimace or physiologic signs incident vs rest pain distinction 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 output stop routine dosing, infusions of morphine breakthrough dosing as 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 pad Insufficient eyelid length Conjunctival exposure increased risk of dryness, pain maintain 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 medications Choose less invasive route of administration buccal mucosal or oral first, then consider rectal subcutaneous, intravenous rarely intramuscular 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 restlessness 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 Lorazepam, 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 congestion Glycopyrrolate, atropine SC or IV Hyoscyamine (SL), scopolamine patch Do not hold sedative medications or opioids because of low respiratory rate, low blood pressure or sedation Continue 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 orders Consider DC NGT/corpak Fan on face for dyspnea Favorite music or quiet Frequent repositioning Frequent re-orientation for confusion Mouth/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 lotion Relaxation techniques Restrict visitors as appropriate Soft lighting Soft touch Speak softly to patient even when comatose Remove 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 IM? 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,微泵用药物 Syringe Driver Medicines,33,Incompatible,Som