中国姑息治疗课件

中国姑息医学的回顾和现状

ReviewandStatusofPalliativeCareinChina

李金祥Dr.JinxiangLi我国姑息医学的发展我国麻醉性镇痛药品的监管法规我国姑息医学的现状我国姑息医学服务的三种模式我国姑息医学实践可获得的药品ThedevelopmentofPalliativecareinChinaTheruleonnarcoticanalgesicmanagementinChinaStatusofPalliativecareinChinaThethreemodelsofPalliativecareinChinaMedicationsofPalliativecareareavailableinChina我国姑息医学的发展（1）

ThedevelopmentofPalliativecareinChina

我国姑息医学服务的常用临床单位名称：

姑息关怀科（成都）临终关怀病房（天津，北京）善终病房（香港）护理院（上海）安宁病房（台湾）宁养院(汕头)

Thenameofpalliativeservicescommonly-usedinChina:Hospice（Chengdu）Wardsforterminalcare(Tianjin,Beijing)Wardsforgooddeath(HongKong)Nursinghomeforterminalillness(Shanghai)Hospitalforpeacefulandcomfortableincommunity(Shantou,Taiwan)1990年卫生部和WHO召开全国癌症专题研讨会，并把癌症三阶段止痛方案推向全国1991年、1994年和1999年我国三次修改吗啡供应办法1990-2000年举行多次全国性癌痛和姑息治疗学习班及临终关怀学习班TheNationalSymposiumonCancerwasco-heldbyMinistryofHealthandWHOin1990,inwhichthethree-stepanalgesicladderwasdisseminatednationwideThesupplyingmeasureofmorphineinChinawasamendedthreetimesrespectivelyin1991,1994and1999Thenation-widecampaignonthestudyofcancer-relatedpainandpalliativecarewascarriedoutformanytimesfrom1990to20001992年及1997年举行了两次全国癌痛现状调查991年卫生部发布第12号文件《关于开展癌症病人三阶梯治疗工作的通知》，号召在全国开展“癌症病人三阶梯止痛治疗工作”Thenationalsurveyonthestatusofcancer-relatedpainwascarriedouttwicein1992and1997respectivelyTheMinistryofHealthissuedthe12thdocumentTheNoticeontheimplementationofthree-stepanalgesicladderoncancer

patients,andcarriedoutthenation-wide“three-stepanalgesicladderoncancerpatientscampaign”in19911993年卫生部出版《癌症病人三阶梯上痛指导原则》，并在全国推广1994年卫生部发布《关于发布癌症病人申请麻醉药品专用卡规定的通知》TheMinistryofHealthissuedTheguidingprinciplesonthethree-stepanalgesicladderoncancerpatientsin1993,anddisseminateditnation-wideTheMinistryofHealthissuedTheNoticeontheIssueoftheRegulationofAnalgesicsApplicationCardbyCancerPatientsin19941998年国家药监局（SDA）160号文件《关于癌症病人使用吗啡极量的通知》，指出：“癌症病人使用吗啡不受吗啡极量限制”1999年华西医科大学与美国AIMS举办第一界国际姑息医学学术研讨会，并建立“姑息关怀病房”和“姑息医学”杂志专栏The160thdocumentTheNoticeontheCeilingDosageofMorphineUsedbyCancerPatientsissuedbyStateDrugAdministration(SDA)in1998pointedoutthat“theamountofmorphineusedbycancerpatientsisnotrestrictedbytheceilingdosageofMorphine”WestChinaUniversityofMedicalSciencesandAIMSoftheU.S.co-organizedTheFirstSeminarofInternationalPalliativeCareofSichuanin1999,andstartedahospicebyDr.JinxiangLiandacolumnofpalliativecareinModernPreventiveMedicineJournal

2000年WHO授权在四川大学建立“WHO华西国际癌症姑息治疗合作中心”2001年李金祥译著<<晚期癌症病人口服吗啡>>writtenbyDr.RobertTwycross2005年李金祥和Dr.RobertTwycross主编《姑息医学》,由人民卫生出版社出版SichuanUniversitywasauthorizedbyWHOin2000tosetup“WHO-HuaxiInternationalCollaboratingCentreforPalliativeCancerCare”JinxiangLitranslatedOralMorphineinadvancedcancerwithAdvancedCancerin2001,abookwrittenbyDr.RobertTwycrossPeople’sMedicalPublishingHousepublished《PalliativeMedicine》,whichwaseditedbyDr.JinxiangLiandDr.RobertTwycross.

一、麻醉性镇痛药品监管政策

1950年11月，公布“管理麻醉药品暂行条例”及实施细则规定由卫生部指定专门药厂生产指定中国医药公司负责供应其它任何机构或个人均不得种植、制造、运输或销售，违者依法论处1.PoliciesForNarcoticAnalgesicManagementInNovember1950,the“TemporaryPolicyonNarcoticmanagement”anditsadministrativedetailsareissued.ItisissuedthattheministryofHealthshouldappointspecialpharmaceuticalcompaniestomanufacturethedrugs.ChinaMedicalCorporationisappointedasthesupplier.Nootherorganizationsorindividualsareentitledtherighttoplant,manufacture,ormarket.Thosewhodisobeythelawwillsufferfromlegalconsequences.1987年重新颁布《麻醉药品管理办法》是我国现行的麻醉药品管理的政策依法加强管理，切实保证医疗、科研和教学上的正当需用，为人民健康服务禁止非法种植、生产、销售和使用，以免发生流弊，转化为毒品，危害人民健康TheNarcoticManagementPolicyre-issuedin1987isthepolicygoverningnarcoticmanagementinChinaatpresent.Enhancemanagementonthebasisoflaw,ensuremedicaltreatmentandtheappropriateapplicationofresearchandteaching,andservethewell-beingofpeople’shealth.Prohibittheillegalplanting,manufacturing,marketing,andapplicationsoastoavoidthecirculationandtransformationofdrugsandthedamagetopeople’shealth.1999年国药监局48号文件《关于癌痛治疗使用麻醉药品有关问题的通知》，“癌痛治疗使用麻醉药品控、缓释制剂时，暂定一张处方不得超过15日常用量对芬太尼透皮贴剂，国家药监局1999年44号文件规定不得超过5贴，1999年48号文件将其用量扩展为不得超过15日AccordingtotheNo.48regulationissuedbytheNationaldrugadministration—TheannouncementonsomequestionsrelatedtoUsingNARCOTICSInthetreatmentofcancer-inducedpain,whenapplynarcoticsinthetreatmentofcancer-inducedpain,theamountofdrugprescribedonetimeshouldnotexceedthecommondoseof15days.AccordingtotheNo.44RegulationissuedbytheNationaldrugadministrationin1999,thenumberofTDFentanylshouldnotexceed5patches.IntheNo.48Regulationissuedin1999,theamountofapplicationwasexpandedto15days.2002年关于印发《癌症患者申办麻醉药品专用卡的规定》，该文件对1994年的文件做了较大修改In2002,theissueof《RegulationofCancerPatientsApplyingfortheSpecificCardforNarcoticAnalgesicsUse》madesignificantchangestotheregulationissuedin1994二、医院麻醉性镇痛药品使用法规:目的：确保麻醉药品的医疗应用和科研需要,严防流入非法渠道

2.TheregulationforusingNarcoticanalgesicsinhospital.Objectives:ensurethemedicalapplicationandresearchrequirementsoftheanalgesics,prohibitthecirculationintotheillegalchannels.

1．短期镇痛、止咳的门诊患者：注射剂不超过常用量，只限患者就诊时使用，严禁交患者自用片剂、酊剂、糖浆剂不得超过3日常用量，连续应用不得超过7天住院病人使用麻醉药品医嘱、病历、手术记录应与处方相符。麻醉镇痛药品连续使用不得超过七天，注射剂不得超过常用量1.Shot-termpainrelief,anti-coughingtoout-patients:Theinjectiondoseshouldnotexceedthecommondose.Theapplicationisonlyrestrictedtowhenthepatientsseekformedicalcare.Theapplicationshouldnotbeleftatthehandofthepatients.Pills,tincture,syrupusshouldnotexceedthecommondoseof3days.Theapplicationshouldnotexceed7daysinarow.Order,historyandoperationrecordsofanalgesicsforin-patientsshouldbeconsistentwiththeprescription.Narcoticanalgesicsshouldnotbeusedformorethansevendays,andinjectionsshouldnotexceedcommondose.3.医师处方麻醉性止痛剂的职责：仅由一位被授权的执业医师负责开处方使用强阿片类药物之前，患者和医师必须对治疗方案和预期效果达成共识，患者必须签署知情同意书3.Theresponsibilityofnarcoticanalgesicsprescripted

byphysician:Onlyoneauthorizedphysicianshouldberesponsibleforprescription.BeforestrongOpioidsused,acommonunderstandingshouldbeobtainedbyboththepatientandphysician,andaninformedconsentneedtobesignedbypatient.

按照三阶梯镇痛疗法，镇痛药物应按时给予病人应至少每周就诊一次，以便调整处方经治医师要定期随访病人，开始时应较频繁（如每周一次）Analgesicsshouldbeadministeredbytheclockandbytheladder.Thepatientneedtoseethedoctoratleastonceaweeksoastoadjustthedosage.Thephysicianshouldfollowuphispatients,morefrequentlyatthebeginning(e.gonceaweek).麻卡期限为二个月，使用期满二个月需继续使用的，凭单位证明信和户口册，重新办理换卡手续办卡必须要见到病人连续使用麻醉药品6个月后，再次更换新卡时，须提供医疗机构的复诊证明Thecardfortheanalgesicsonlyvalidfor2months.Ifthecardneedtobeusedcontinuously,renewalcouldbeappliedwithatestimonialprovidedbythepatient’sworkunitandresidencebooklet.Thepatientshouldbepresentedontheoccasionofcardapplication.AftercontinuouslyNarcoticAnalgesicsusefor6months.Testimonialforre-diagnosisofferedbythehospitalisneededonrenewal.对于使用卡的病人，医生必须每月面诊病人，建立大病历，记录病人的疼痛情况病人去世后交回麻卡并无偿交回剩余的麻醉药品Thephysicianandpatientwithacardshouldmeeteverymonth,andmedicalrecordsshouldbeestablishedtorecordpainstatusofthepatient.Thecardshouldbehandinandremainednarcoticanalgesicsshouldbereturnedwithoutcompensationafterthepatient’sdeath.住院和门诊患者在开具控缓释制剂时，可同时使用即释麻醉药品，以缓解活动时的剧痛晚癌病人不提倡使用度冷丁盐酸二氢埃托啡片只限二级以上医疗机构的住院病人使用Normal-releaseandcontrol-releasenarcoticanalgesicsmayconcurrentlybeusedtorelieveseverepaininmovementforin-andout-patients.Pethidineisnotrecommendedforpainreliefinadvancedcancer.Dihydroetorphinehydrochlorideshouldonlybeusedinhospitalsonandabove2ndlevel.三、医师开具处方的规定：具有执业医师资格，经市级以上卫生主管部门考核合格,并能正确使用麻醉药品，才能授予麻醉药品处方权开具麻醉药品应使用专用淡红色纸质处方，按照《处方管理办法》的规定开具处方。处方上写明临床诊断3.Regulationofphysician’sprescriptionNarcoticanalgesicprescribingauthorityshouldonlybeauthorisedtocertifiedphysicianswhohavepassedexaminationsheldbymedicaladministrativedepartmentabovecitylevelandareabletousenarcoticanalgesiccorrectly.Narcoticanalgesicsshouldbeprescribedwithpaleredprescribingpaperandaccordingtotherulesin<PrescriptionAdministrationRegulation>.Clinicaldiagnosisofcancershouldbewrittenclearlyontheprescriptionpaper.四.麻醉药品管理方面的规定

RegulationsonNarcoticanalgesicmanagement五.专管理:专人负责,专柜架锁专用账册,专用处方专册登记

FiveSpecificManagement:

specificpersoninchargespecificlockedcabinetspecificcounterspecificprescriptionspecificregistration

发达与发展中国家2002年的吗啡医疗消耗量

TheContrastontheAmountofMedical

MorphineConsumptionbetweendevelopedcountriesandthedevelopingcountriesin2002

国家n

人口population医疗消耗量Medicalconsumption百万million%kgMg/人%A271049.726.72541224.2192.8

B672886.773.319610.687.2C—1295.332.92530.1950.9A：发达国家(developedcountry)B：发展中国家(developingcountry)C：中国(China)

六.麻醉药品合法使用中的问题最大障碍是“成瘾恐惧症”病人药品用量不足麻醉药品品种使用不合理三阶梯癌痛治疗必须进一步推广医生和患者对疼痛治疗的重视程度需要提高6.LegaluseofnarcoticanalgesicsThestrongestobstacleis“opiophobia”InsufficientdoseofthenarcoticanalgesicsUnappropriateuseofthenarcoticanalgesics3-stepanalgesicladdershouldbegeneralizedDoctors’andpatients’emphasisonpainreliefshouldbestrengthened.

我国姑息医学的服务现状

StatusofPalliativecareserviceinChina

多种临床服务模式：专科住院服务单位（hospice）—姑息关怀科，临终关怀医院，护理院,疼痛科（麻醉科大夫）兼代癌痛控制单位—肿瘤科，老年科和内科医师兼代从事癌痛控制社区关怀服务单位—宁养院（上门巡诊与电话随访相结合）

MultipleClinicalServiceModels:Hospice–DepartmentofPalliativeCare,TerminalCare,nursingdepartment,pain-reliefDepartment(physicianofanesthesia)DepartmentConcurrentInChargeofcancerpainrelief—CarcinomaDepartment,SenilityDepartment,andphysiciansconcurrentlytakingchangeofcancerpainrelief.Careunitincommunity—NingYangYuan(thecombinationofhomevisitandtelephonefollow-up.

住院服务单位(1)

AdmissionServiceUnit(1)

姑息关怀科:控制疼痛和缓解症状,改善生存质量；末期关怀照护,为末期病人提供善终服务临终关怀医院:针对慢性心肾肺脑患者,高龄老人提供照护起居,日常生活,心理辅导和末期关怀服务PalliativeCareDepartment:paincontrolandsymptomrelief,improvethequalityoflife,terminalcare,providegood-deathservicetopatientswithterminaldisease.HospitalforTerminalCare:providepsychologicalcounseling,andterminalcareserviceforpatientswithchroniccardial,pneumonic,renal,andheartdiseaseandoldpeople.住院服务单位(2)

AdmissionServiceunit(2)

兼代癌痛控制单位:

肿瘤科、老年科和内科医师在抗癌治疗同时,兼代作癌痛治疗,能熟练应用“WHO三级镇痛阶梯”,但不少医生担心成瘾和呼吸抑制,仍停留在肌注杜冷丁镇痛Unitsconcurrentlyinchargeofcancerpainrelief:

Oncologicdepartment,thegeriatricdepartment,andphysicians,whilemakinganti-cancertreatment,alsomadecancerpainreliefeffort.Theycanskillfullyusethe“WHO3-stepanalgesicladderforcancerpain.However,manyphysiciansworryabouttheaddictionandrespiratorydepression,sotheystillstayatthestageofmuscle-injectionofpathedine.

住院姑息关怀服务单位

TheUnitsofPalliativeCareforAdmission川大华西第四医院姑息关怀服务

ClinicalServiceofpalliativecareinWestChinaFourthHospitalofSC病房有22张床,一个诊断室,4名医生13名护士,其中专职从事姑息关怀服务的3名医生和1名护士在英国牛津受过专业培训收治晚期癌症和无生物学前景的末期疾病患者医生每天查房两次(上午和下午),1名医生和1名护士全天24小时值班Thereare4physiciansand13nursesinthewardswith22beds.Toprovidetheserviceforterminalpatientsinadvancedcancerandnoprospectofbiology.Doctorsarewardroundeveryday,adoctorandanurseareondutyfor24hoursonrotation.多数病人来自门诊,部分病人从其他医院转来姑息治疗知识主要来源于Dr.Robert

的几本著作严格将“WHO三级镇痛阶梯”用于临床住院病人应用无极限剂量阿片类药物,门诊病人一张处方的阿片类应限制在3-7天内的药物

Mostofpatientscomefromout-patient,somepatientsaretransferredfromotherdepartments.KnowledgeofpalliativecaremainlycomesfromDr.RobertTwycross’sseveralbook.UsetheWHOthree-stepanalgesicladder.Useofopioidsisnotlimitedinthewards,butprescriptionofopioidsforoutpatientislimitedinthreedays.

门诊病人凭当地药品监管的“麻卡”购买阿片类必要时作姑息性放化疗以控制症状不再做拖延死亡的治疗和终末期病人的复苏治疗Patientsatout-patienthavetohavespecialcertificatefromLocalHealthBureauforprescriptionofopioids.Developpalliativeradiotherapyandchemotherapyforsymptomcontrol.Nolongeradvisetreatmenttopostpone-death,notcardiopulmonaryresuscitationtoterminalpatients.对症状提供理疗,但无工疗病房无义工,神职人员没有日托和淋巴水肿的服务,护理主要是家属和/或雇人照护应用中西医结合控制症状和疼痛宣传姑息关怀的概念,培训和教育相关的医护人员Usephysiotherapy,noserviceofoccupationaltherapy.Nosocialworker,chaplainandvolunteerinhospital.Nodaycentreandlymphoedemaservices,carersaremainlyrelatives.Usecombinationwestmedicineandtraditionalmedicineforsymptomcontrol,suchasacupunctureandherbsforpainrelief.Propagandatheideaofpalliativecare,anddevelopthetrainingandeducationforhealthprofessionals.

社区姑息关怀服务单位:宁养院

PalliativeCareUnitsinCommunities:

NingYangYuan

宁养院:“宁养”含宁静，养护的意思，实际上是一种姑息关怀机构于2001年在汕头成立全国首家宁养院,现共有20家NingYangYuan:“NingYang”connotesquietnessandrecuperation.ItisinfactatypeofPalliativeCareUnit.ThefirstNingYangYuanofthecountrywassetupin2001inShantou.Nowtherearealltogether20suchunitsinChina.

20家宁养院分布图TheDistributionofThe20NingYangYuan

汕头大学医学院第一附属医院(总院)

·北京天坛医院(Beijing)

·福建省立医院(Fujian)

·深圳市人民医院(shenzhen)

·天津市第一中心医院(tianjin)

·广东医学院附属医院(guangdong)

·中国医科大学第二附属医院(Beijing)

·大连医科大学第一附属医院(dalian)

·上海第二医科大学附属新华医院(shanghai)

·哈尔滨医科大学附属肿瘤医院(Haerbin)

·武汉大学中南医院(wuhan)北京肿瘤医院(Beijing)·广东粤北人民医院(Guangdong)

·广东潮州市中心医院(Guangdong)

·兰州医学院第一附属医院(Lanzhou)

·江西医学院第一附院(jiangxi)·新疆医科大学附属肿瘤医院(xijiang)

·广西医科大学第一附属医院(guangxi)

·暨南大学医学院第一附属医院(guangzhou)

·重庆医科大学第一附属医院(chongqing)宁养院的分布宁养院服务的模式

TheservicemodelofNingYangYuan

对晚期贫困癌症病人上门免费服务“以人为本，全人服务”居家服务，咨询服务，门诊服务镇痛治疗，心理辅导，宁养知识宣教Charge-freeserviceathomeforthosepoorpatientsinadvancedcancer“Peoplebeingthemostimportant,whole-personservice”ServiceProvidedathome,counselingservice,andout-patientservice.Painrelief,Psychological,andtheinformingofNingYangknowledge.综合性医院末期疾病患者的治疗现状

Thestatusofpatient’sManagementforterminalillnessinthegeneralhospitals

＞80%末期疾病患者未得到疼痛缓解和症状控制许多病人及家属要求安乐死,少数甚至因为无法忍受躯体和心理上的痛苦而自杀>80%ofthecancerpatientsatterminalstagehaven’tgotsymptomcontrolandpainmanagementmanypatientandrelativesrequesteuthanasia,afewevencommitsuicidetoavoidtoexcruciatingcancerpainalongwithphysicalandemotionaldistress.坚持放化疗直到死亡对末期患者坚持“不惜一切代价”救治生命的理念insistonradiotherapyandchemotherapyuntilpatientdeath.insistontheprincipleoflife-saving“atallcosts”toterminalpatients.

对濒死患者进行延长死亡的维持治疗,如输液,输血,输营养等直到死亡尽管心跳呼吸已经停止,仍然进行心肺复苏,人工通气,心内注射,胸壁按压Stillmaintaintreatmentsforprolonging-deathatterminalphase,suchasinfusion,bloodtransfusion,nutrition,antibioticsinfusionandoxygen,untilpatientdeath.Continuecardiopulmonaryresuscitation,persistentlyartificialventilationusingamask,useintra-cardiacinjectionafterthecardiopulmonaryStopped,compressionofthechestwalltomaintaincirculation.

受传统观念影响,内科医生担心阿片成瘾,呼吸抑制,缺乏新的科学知识,他们决不用吗啡缓解疼痛,但坚持使用哌替定(杜冷丁)镇痛卫生执业者与病人及家属缺乏恰当的交流,极少告之诊断,决不谈论预后和死亡Physicianworryaboutopioidaddiction,respiratorydepressionandlacknewscientificknowledge,theyneverusemorphinetoreliefpainforthedyingpatient.But,theyalwaysusepethidineforpainrelief.Lackofcommunicationsbetweenhealthprofessionals,patientsandrelatives,nevertellpatientsabouttheirdiagnosisandprognosis.

可供晚期恶性疾患治疗应用的药物

medicationsformalignentillnessesareavailableinChina阿片类药物opioids非阿片类药物non-opioids辅助类药物adjuvantanalgesics其他类药物others

阿片类药物

opioids强阿片类药物strongopioids吗啡缓释片:美菲康

MorphineHydrochlorideControlled-releaseTablets吗啡控释片:美施康定

MorphineSulfateModified-releaseTablets吗啡即释片morphinenormal-release吗啡针剂morphineforinjectablesolution

强阿片类药物strongopioids美沙酮methadone:戒毒芬太尼透皮剂TDfentanyl

羟考酮oxycodone布托啡诺鼻喷剂butorphanolnasalspray盐酸二氢埃托啡dihydroetorphine丁丙喏啡buprenorphine弱阿片类药物weakopioids曲马多tramadol可待因codeine哌替啶pethidine双氢可待因dihydrocodeine复方制剂：opioidcompoundpreparations氨酚羟可酮Mallinckrodt:Oxycodone5mg

Acetaminophen325mg阿片类拮抗剂：opioidantagonist纳洛酮naloxone非阿片类药物non-opioids阿司匹林Aspirin对乙酰氨基酚Acetaminophen非甾类抗炎药物NSAIDs非甾体类抗炎药(NSAIDs)：双氯芬酸钠diclofenac

氟布洛芬flubiprofen罗非昔布rofecoxib

塞莱昔布celecoxib美洛昔康

meloxican

氯诺昔康lomaxicam布洛芬ibuprofen

萘普生naproxen吲哚美辛indometacin辅助类药物adjuvants

皮质类固醇激素steroids抗癫痫类anti-epileptics精神抑制性药物neuroleptics:TCASSRI

苯并二氮卓类benzodiazepines止吐药anti-emetics缓泻剂laxatives其他药物

others皮质类固醇激素Steroids：地塞米松dexamethason强的松prednisone强的松龙prednisolone抗癫痫类Anti-epileptics

盖巴丁gabapentin苯妥因phenytoin卡马西平carbamazepine精神抑制性药物Neuroleptics三环类(TCA):阿米替林Amitriptyline

氯丙咪嗪clomipramine

去甲丙咪嗪desipramine丙咪嗪imipramine多虑平doxepin

去甲替林nortriptyline

选择性5-羟色胺重摄取抑制剂（SSRIs）氟西汀Fluoxetine

帕洛西汀Paroxetine

舍曲林Sertraline米氮平Mirtazapine

文拉法辛Venlafaxin苯并二氮卓类Benzodiazepines

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