Recognition of Palliative Care in Chinese Clinicians: How They Feel and What They Know

Objective To investigate doctors’ feelings when providing medical care to end-stage patients, and their understanding as well as reflection about theoretical concepts of palliative medicine. Methods Questionnaires were delivered through a social networking platform to 1500 clinicians of different specialties in 10 proviences of China. It covered issues of background information, self-assessment of familiarity to palliative care, prior training history, emotional attitude toward end-stage patients, and the reflections on clinical practice. Logistic regression analysis and chi-square test were used to analyse the categorical variables. Results There were 379 clinicians who completed the questionnaires and submitted successfully. Among them, 66.8% (253/379) had attended palliative care training courses more than twice; 66.8% (253/379) clinicians percieved powerless feeling when facing end-stage patients. We found that the education on palliative medicine was significantly associated to doctors’ better comprehension on the concept of palliative care (OR=6.923, P=0.002). Doctors who were more familiar with palliative medicine were less likely to perceive powerless feelings (χ ²=13.015, P<0.001), and would be more likely to concern about patients and their family members in their clinical work (χ ²=28.754, P<0.001, χ ²=24.406, P<0.001). Conclusion The powerless feeling is prevalent in Chinese doctors when facing end-stage patients. Palliative care help them overcome the negative feelings and act more caring in clinic. More careful designed educational strategies that adapt to Chinese actual situation are needed to improve doctors’ cognition on palliative care.     

三甲医院缓和医疗会诊服务实践存在的问题分析

目的 探究三甲医院院内缓和医疗会诊服务在实践过程中遇到的障碍,针对这些困难提出意见和建议,为院内缓和医疗会诊服务的进一步开展提供参考。方法 对北京协和医院17名请求过缓和医疗会诊服务的医护人员进行半结构式访谈,对相关资料进行整理、分析。结果 院内缓和医疗会诊服务开展中的障碍因素包括患者及家属对缓和医疗了解不够深入、医护人员对缓和医疗的认知不够深刻、临床诊疗团队对会诊意见落实不够全面、缓和医疗会诊团队提供服务的精力有限、缓和医疗的开展难以创造所谓的经济效益5个方面。同时,针对院内缓和医疗会诊服务开展过程中的障碍和不足,提出工作改进的建议包括增加患者及其家属对缓和医疗的接受程度、提高医护人员对缓和医疗知识水平、建立会诊团队与医护人员的新型合作模式、增强医院对缓和医疗发展的制度保障和建立健全缓和医疗相关法律政策等。结论 三甲医院院内缓和医疗会诊服务在实践过程中虽然遇到很多困难和障碍,但是医护人员对缓和医疗的需求和期望仍在提高。     

Running a Volunteer Program for Palliative Care in a Chinese Hospital: Our Practice and Experience

The establishment and development of volunteer team are very important in the whole process of palliative care. The concept and practice of palliative care have been developed in Peking Union Medical College Hospital (PUMCH) since the end of 2012. Great progress has been made in different aspects. Volunteers play an extremely important role in the development of palliative care in PUMCH. The whole work began with the establishment of volunteer teams. This article introduces the process of the establishment and development of palliative care volunteer team in PUMCH, aiming to provide practical references for hospitals in mainland China to develop their own palliative care volunteer team.     

Hospice and Palliative Care in Mainland China: History,Current Status and Challenges

The concept of End-of-Life Care (EOLC) came into China in the late 1980s. However, hospice and palliative care in medical practice develope slowly. In recent years, profesionals, patients and their families, as well as government begin to attach importance to it. There is a hospice and palliative care movement now in China. This article gives an overview of the progress and the current status in multiple aspects of hospice and palliative care in mainland China, and points out the barriers and challenges for its further development in the future.     

Gaps in end-of-life care

End-of-life care is an important aspect of medical practice. Individual physicians and the medical community must be committed to the compassionate and competent provision of care to dying patients and their families. Patients rightfully expect their physicians to care for them and provide them with medical assistance as they are dying. To care properly for patients near the end of life, the physician must understand that palliative care entails addressing physical, psychosocial, and spiritual needs and that patients may at times require palliative treatment in an acute care context. To provide palliative care, the physician must be up to date on the proper use of opioids and the legality and propriety of using high doses of opioids as necessary to relieve suffering. Good symptom control; ongoing involvement with the patient; and physical, psychological, and spiritual support are the hallmarks of quality end-of-life care. Care of patients near the end of life, however, has a moral, psychological, and interpersonal intensity that distinguishes it from most other clinical encounters. With appropriate education, physicians can play a key role to improve care for patients and families who are living with advanced life-threatening illness. Although some issues (e.g., the role of physician-assisted death in addressing suffering) remain very controversial, there is much common ground based on the application of the four major principles of medical ethics, nonmaleficence, beneficence, autonomy, and justice.     

开设安宁疗护课程在医学院校教育中的意义

近几年,政府主导下的安宁疗护在中国大陆地区逐步兴起,安宁疗护学术组织、学术会议逐渐增多,试点单位陆续启动,促进了安宁疗护的蓬勃发展。安宁疗护的核心思想是强调人本主义、身心社灵整体观和科学的死亡观,是最贴近医学本质的临床学科。因此,很有必要在医学院校开设安宁疗护的相关课程,并把它作为专业素养教育的一个重要组成部分。医学生通过学习和实践安宁疗护相关理念和知识,才能在未来更好地为患者提供高品质的医疗健康服务。通过梳理安宁疗护现状和需求以及医学院校开设安宁疗护相关课程的国内外现状,为中国开展安宁疗护医学教育,培养专业人才提供参考。     

姑息治疗与安宁疗护基本用药指南

姑息治疗与安宁疗护是通过多学科协作的模式,有效改善患者的痛苦症状、提高生活质量,直至其舒适、有尊严离世的新兴临床学科,适用于各年龄阶段,罹患现代医学无法治愈,并伴有躯体和/或精神心理症状,严重影响生活质量的疾病终末期和临终期患者。合理使用药物是姑息治疗与安宁疗护中最为重要的内容之一,因此,指南工作组依照国际指南的制定标准、结合国内外相关研究和临床实践,制订了我国首部《姑息治疗与安宁疗护基本用药指南》。该指南围绕各种疾病终末期和临终期患者常见的33个全身性和各系统的躯体、精神心理症状及难治性症状,推荐23种治疗药物,其中20种药物收录于我国现行《国家基本药物目录》。为便于广大医务人员参阅学习,指南详细阐述了姑息治疗与安宁疗护专科的基本理论、临床用药原则、相关药物的用法用量和注意事项等内容。该指南的制定有助于提升各临床学科对疾病终末期和临终患者的诊疗服务质量,是确保患者获得舒适与尊严性医疗服务的基本保障,同时填补了我国姑息治疗与安宁疗护学科发展的空白。     

肿瘤支持/姑息治疗的回顾与展望

肿瘤患者支持/姑息治疗是一项涉及范围广泛、整体、全方位的诊疗体系;成功的支持/姑息治疗贯穿于疾病诊断、治疗、终末期全程以及癌症生存者(包括治疗和康复者)管理等;其在疾病不同阶段目标不同。介绍美国临床肿瘤学会(ASCO)、欧洲肿瘤内科学会(ESMO)、美国国家综合癌症网络(NCCN)等学术组织颁布的多项支持/姑息治疗相关指南重点更新,为中国的肿瘤支持/姑息治疗发展带来全新的思考和借鉴。     

Value-based Practice: Integration of Cancer Rehabilitation and Palliative Care in Oncology Services

Value-based care model has been evolving to organize medical services around the patient and provide the full cycle of care for a medical condition. The full cycle of care model encompasses inpatient, outpatient, rehabilitation as well as supportive care such as palliative care and nutrition support. Cancer rehabilitation and palliative care have emerged as two important parts of value-based practice for oncology patients. More clinical evidence suggests that early intervention of oncology rehabilitation program and palliative care are likely to improve the patient outcome and reduce the overall medical cost for the patient and his or her family as well as for medical service providers. Although interest has been raised in Chinese oncologists, but effectiveness of incorporating these two services in clinical practices has not been adequately demonstrated. An understanding of scope of cancer rehabilitation and palliative care may help facilitate the integration of both into the oncology care continuum in efforts to improve patients' physical, psychological, cognitive, functional health and quality of life.     

三级医院急诊医师对缓和医疗的认知和能力

目的 了解国内急诊医师对缓和医疗的认知和相关能力现况。方法 采用便利抽样法抽取中国115名三级医院急诊医师进行问卷调查。问卷内容包括:基本信息;面对终末期患者/家属的感受、态度;对缓和医疗的认知;个人缓和医疗能力。结果 对缓和医疗认知程度自评为“不了解”、“部分了解”和“充分了解”的急诊医师占比分别为25.2%、59.1%、15.7%。参加过缓和医疗相关讲座的医师32人(27.8%),其自评认知程度更高(P=0.002)。微信(39.1%)、媒体(36.5%)、口口相传(33.0%)是急诊医师获得缓和医疗知识的前3位途径。68.7%的急诊医师面对终末期患者有“无力感”,60.9%和59.1%的医生感到纠结和担心死亡引发纠纷。急诊医师在缓解患者撤除呼吸机后的呼吸困难[3(2,4)]、消除临终恐惧心理[3(3,4)]等方面的能力自评指数较低。急诊医师对缓和医疗的认知程度(自评)与大部分的缓和医疗能力自评指数项呈正相关。结论 讲座对急诊医师的缓和医疗认知程度有显著影响;在自评中,多数缓和医疗能力项与缓和医疗认知程度呈正相关。面对终末期患者时,多数急诊医师存在无力、纠结、担心纠纷等情绪,在缓解患者撤除呼吸机后的呼吸困难、消除临终恐惧心理等方面的能力自评指数较低,相关培训可作为重点。     

舒缓医学教育在老年医学专业教学中的实践

本文介绍了国内外舒缓医学发展历史,调研了舒缓医学教学在老年医学中存在的问题;对改善老年医学舒缓医学教育进行探索,采用理论授课、临床实习（PBL教学、案例教学及叙事医学教学）等开展老年医学专业研究生舒缓医学教育。结果表明,67.9%的学生增加了舒缓医学的学习感,92.5%的学生认为舒缓医学非常重要,75%的学生认为增强了语言表达能力、与患者晚期疾病沟通能力即临终关怀能力。     

军队医院野战医疗所在海上灾害时医疗救援的实践

目的探讨军队医院野战医疗所在平时海上灾害时医疗救援的展开效果,提高海上突发事件的救治能力。方法针对海上突发事件不同规模,探讨野战医疗所的10、15、50和120人的编组构成与展开流程。结果本研究1026例伤病员中,存活987例(96.2%),死亡39例(3.8%);伤后1 h以内死亡9例(23.1%),24 h以内死亡23例(59.0%);死于创伤合并症者36例(92.3%),溺水死亡2例(5.1%),中毒死亡1例(2.6%)。结论军队医院野战医疗所通过平时海上灾害时医疗救援的实践,提高了海上灾害医疗救援的快速反应能力、整体配合能力和救护水平,丰富了军队医院野战医疗所的救护内容与经验。     

关于恶性肿瘤患者家属对自然安宁死认识的调查分析

目的 了解恶性肿瘤患者相关治疗情况及心理,了解家属对自然安宁死的认识.方法选择五所医院肿瘤科患者家属进行问卷调查,并进行数据处理分析.结果 手术治疗加化疗放疗导致了医疗费用的增加,患者经过放疗化疗处于痛苦状态但肯定治疗产生的作用;被调查的大部分患者家属认为可以或应该让患者知道自己的病情;分析调查结果后认为,末期病人的安宁治疗有较好的群众基础,但自然死还较不能被接受,而宁养院病区的患者家属肯定安宁治疗.结论 应明确界定恶性肿瘤末期阶段;加强自然安宁死的宣传;政府应该积极推进自然安宁死制度建设.     

缓和医疗在老年医学硕士研究生培养中的整合探究

随着我国人口老龄化进程加剧,高龄化趋势也在不断发展。老年期疾病具有多病共存、慢病高发、并发症多见等特点,严重影响患者生活质量。老年患者面临严峻的医疗挑战及社会、心理等多种问题,治疗复杂性增加。作为未来临床诊疗的主要力量,老年医学专业硕士研究生承担着积极应对人口老龄化的社会责任,需通过加强缓和医疗师资队伍建设、增设研究生缓和医疗课程教学、临床实践中增加缓和医疗模式体验、指导研究生向患者与照护者加强缓和医疗知识宣教及健全缓和医疗考核评估体系等,在老年医学硕士研究生培养体系中将缓和医疗知识进行整合,可以提升教学效果,减轻患者及照护者的医疗负担,并能够有效治疗疾病、避免过度医疗及医患纠纷发生。     

社区安宁疗护服务对象准入准出标准研究

目的 构建上海市社区安宁疗护准入、准出标准,以指导社区筛选出真正属于安宁疗护范畴并急需照护的人群。 方法 通过文献回顾和焦点小组访谈确定出安宁疗护服务对象的准入、准出判断维度;于2017年7—8月间邀请6家上海市安宁疗护试点单位安宁疗护科资深执行人和管理者代表,经过两轮Delphi咨询,采集各位专家对社区安宁疗护准入、准出标准的意见。 结果 社区安宁疗护服务对象准入的4个判断维度分别是:病种、生存期、症状、患者和家属的主观意愿;准出的3个判断维度分别是:患者和家属的主观意愿、症状、患者死亡。居家和机构安宁疗护准入标准的差异主要体现在:病种(机构比居家多一个脑血管病)、生存期(居家倾向于<180 d,机构倾向于<90 d)、症状(机构可以处理更多的临床症状)。居家和机构安宁疗护准出标准的差异主要体现在机构准出标准需考虑临床症状缓解、生存期延长等因素。 结论 本研究梳理的社区安宁疗护准入、准出标准,与现有的安宁疗护标准相比,补充了生存期的其他要求,明确了病种范围,并综合考虑了社区安宁疗护试点单位的服务能力和服务对象意愿的表达方式,新增了准出标准,为居家安宁疗护、机构安宁疗护和综合医院间有序转介奠定了基础。      

北京协和医院老年病房终末期患者的住院费用及构成

目的 了解北京协和医院老年病房中末期患者的住院费用及构成情况,为进一步研究安宁缓和医疗的卫生经济学价值提供依据。方法 浏览北京协和医院老年医学病房2018年内入院的患者病史,根据统一标准,选取适合进入安宁疗护的终末期患者,收集并归纳重要人口学信息及病情情况,对住院费用及其组成进行计算。结果 共有35例患者入选,其中,男20例,女15例,平均年龄(78±8)岁(59~91岁),平均年龄校正查尔森合并症指数10±3,中位日常生活活动能力评分40(10,70)分;晚期恶性肿瘤23例,慢性心力衰竭4例,终末期慢性肾脏疾病1例,终末期肝病2例,痴呆4例,其他严重疾患3例。患者在院期间接受规范内科、老年医学科治疗,最终死亡8例,出院27例。35例患者的中位住院天数为15(12,23)d,中位住院费用为2.15(1.38,3.76)万元,中位日均费用1425(970,2503)元;平均药费占比(28.5±12.3)%,检查检验费占比(33.2±18.0)%,中位床位费占比11.5%(6.4%,15.8%);日均控制症状药物费用(77±58)元,平均占总住院费比例为(5.2±3.5)%。结论 与基层医院的安宁疗护病房相比,终末期患者入住三级医院老年病房的费用较高。费用组成方面,药费与检查费占比接近,症状控制费用较低。我国需进一步研究安宁缓和医疗对终末期患者医疗费用的影响。     

综合医院28例腹盆腔癌症终末期患者的安宁疗护实践

目的 总结28例腹盆腔癌症患者终末期的安宁疗护护理,便于指导安宁疗护临床实践。 方法 选取2017年5月至2018年12月西南医科大学附属医院肿瘤科收治的28例腹盆腔癌症终末期患者,对患者及其家属实施以护士为主导的医护一体、多学科合作的安宁疗护共照团队护理,分别对患者实施症状管理、舒适护理、心理照护、死亡教育,对患者亲属实施哀伤辅导等。结果 总结安宁照护行为对其结局指标的影响,28例患者均制定预立医疗照护计划。通过症状管理,25例(89.28%)患者腹胀症状明显缓解,28例患者疼痛得到有效控制,NRS评分维持在0~3分,水肿症状得到有效缓解,5例双下肢水肿患者出现张力性水泡,护理后无一例出现皮肤破溃和感染。25例(89.28%)患者在家属陪伴及医护见证下对生命末期治疗及护理、死亡地点的选择、抢救与否、遗体处置等事宜作出安排。临终治疗抉择:仅3例(10.71%)选择心肺复苏;1例(3.57%)选择气管插管;0例选择电击除颤和入住ICU病房;其中1例在安宁疗护共照团队协助下完成眼角膜捐献。结论 通过构建以护士为主导的医护一体、多学科合作的安宁疗护共照团队模式,可以提高腹盆腔癌症终末期患者舒适感,缓解症状,帮助患者及家属正确面对死亡。     

网上医疗中一种有效的医生行为控制机制

实用的网上医院必须能够对医疗行为进行有效控制，然而已有研究表明。大多缺乏对医疗行为的不可控制性进行深入讨论，致使网上医院无法真正为患者提供实用的服务。为此，通过基于医疗行为信任预测与博弈分析相结合。提出了一种适用于网上医院医疗行为的控制机制。为确保该机制的有效性。给出了基于该机制对网络医疗行为实施控制的具体过程。此外，还详细讨论了该机制与其它传统机制相比较所具备的优势。     

北京协和医院院内缓和医疗会诊对医护人员的影响

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