晚期肿瘤患者安宁疗护实践中的认识误区、伦理困境及对策探讨
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摘要
自《安宁疗护实践指南(试行)》和《安宁疗护中心基本标准和管理规范(试行)》发布以来,国内多家医疗机构、护理院、养老院纷纷建立了安宁疗护病区或病床,安宁疗护事业进入了新的发展阶段。由于理论和实践经验不足,服务中存在着概念不清、重心不明等问题,包括将安宁疗护等同于缓和医疗、关注护理而非治疗、重心理轻生理等认识误区,且面临着传统医疗模式与安宁疗护理念冲突,病情保密与患者知情、家庭决策与患者自主等伦理困境。文章针对晚期肿瘤患者安宁疗护实践中的一些认识误区和伦理困境进行了阐释,并提出了相应的对策。
Since the publication of the "Guidelines for the Practice of Hospice Care(for Trial Implementation)"and the"Basic Standards and Management specification for the Hospice Care Center(for Trial Implementation)",many medical institutions and nursing homes in China have established hospice care units or onwards. The establishment of hospice care has entered a new phase. Due to insufficient theoretical and practical experience,there are many problems such as unclear concepts and uncertain concerns in the service,including equating hospice care with palliative care,paying attention to care rather than treatment,focusing on mental rather than physiology,and other misunderstandings. Moreover,there are many ethical dilemmas in the process of service such as the conflicts between traditional medical models and hospice care concepts,confidentiality and informed understanding,family decision-making and patient autonomy. This paper unravels some misunderstandings and ethical dilemmas in the practice of hospice care for patients with advanced tumor,and proposes corresponding countermeasures.
Since the publication of the "Guidelines for the Practice of Hospice Care(for Trial Implementation)"and the"Basic Standards and Management specification for the Hospice Care Center(for Trial Implementation)",many medical institutions and nursing homes in China have established hospice care units or onwards. The establishment of hospice care has entered a new phase. Due to insufficient theoretical and practical experience,there are many problems such as unclear concepts and uncertain concerns in the service,including equating hospice care with palliative care,paying attention to care rather than treatment,focusing on mental rather than physiology,and other misunderstandings. Moreover,there are many ethical dilemmas in the process of service such as the conflicts between traditional medical models and hospice care concepts,confidentiality and informed understanding,family decision-making and patient autonomy. This paper unravels some misunderstandings and ethical dilemmas in the practice of hospice care for patients with advanced tumor,and proposes corresponding countermeasures.
引文
[1]国家卫生健康委员会.关于安宁疗护中心基本标准,管理规范及安宁疗护实践指南的解读[EB/OL].[2017-02-09]. http://www.nhfpc.gov.cn/yzygj/s3593/201702/f12b1c7868194dd0ba1c658b32f8b59f.shtml
[2]国家卫生和计划生育委员会.国家卫生计生委办公厅关于印发安宁疗护实践指南(试行)的通知[EB/OL].[2017-02-09]. http://www. moh.gov. cn/yzygj/s3593/201702/83797c0261a94781b158dbd76666b717. shtml
[3] The 2015 Quality of Death Index[EB/OL].[2018-08-18]. https://www.basw.co.uk/system/files/resources/basw_94746-1_0.pdf
[4]陈万青,孙可欣,郑荣寿,等. 2014年中国分地区恶性肿瘤发病和死亡分析[J].中国肿瘤,2018,27(1):1-14
[5] Zou M,O’connor M,Peters L,et al. Palliative care in mainland China[J]. Asia Pacific Journal of Health Management,2013,8(1):9-13
[6] WHO definition of palliative care[EB/OL].[2018-08-18]. http://www.who.int/cancer/palliative/definition/en/
[7] National Institutes of Health. What are palliative care and hospice care?[EB/OL].[2018-12-03]. https://www.nia.nih.gov/health/what-are-palliative-care-and-hospice-carerequirement
[8]周玲君,沈伟,赵继军.癌症患者临终阶段症状特点及与生存期的关系[J].护理学杂志,2009,24(6):6-8
[9] Mh VE,Hochstenbach LM,Joosten EA,et al. Update on prevalence of pain in patients with cancer:systematic review and meta-analysis[J]. J Pain Symptom Manage,2016,51(6):1070-1090
[10] Teunissen SM,Wesker W,Kruitwagen C,et al. Symptom prevalence in patients with incurable cancer:a systematic review[J]. J Pain Symptom Manage,2007,34(1):94-104
[11] Ong WY,Yee CM,Lee A. Ethical dilemmas in the care of cancer patients near the end of life[J]. Singapore Med J,2012,53(1):11-16
[12] Turkoski BB. Home care and hospice ethics:using the code for nurses as a guide[J]. Home Healthc Nurse,2000,18(5):316-317
[13] Cheon J,Coyle N,Wiegand DL,et al. Ethical issues experienced by hospice and palliative nurses[J]. Journal of Hospice&Palliative Nursing,2015,17(1):14-15
[14] Chiu TY,Hu WY,Chen CY. Ethical dilemmas in palliative care:a study in Taiwan[J]. J Med Ethics,2000,26(5):353-357
[15]Daugherty CK. Examining ethical dilemmas as obstacles to hospice and palliative care for advanced cancer patients[J]. Cancer Invest,2004,22(1):123-131
[16]Mccabe MS,Coyle N. Ethical and legal issues in palliative care[J]. Semin Oncol Nurs,2014,30(4):287-295
[17]于虎,沈开金,敖其,等.急诊心肺复苏4年间变化趋势的单中心研究[J].中华危重病急救医学,2014(10):734-736
[18] Sehatzadeh S. Cardiopulmonary resuscitation in patients with terminal illness:an evidence-based analysis[J].Ont Health Technol Assess Ser,2014,14(15):1-38
[19]Kj?rstad OJ,Haugen DF. Cardiopulmonary resuscitation in palliative care cancer patients[J]. Tidsskr Nor Laegeforen,2013,133(4):417-421
[20] Granda-Cameron C,Houldin A. Concept analysis of good death in terminally ill patients[J]. Am J Hosp Palliat Care,2012,29(8):632-639
[21]张新庆,王云岭,韩跃红,等.“生命尊严”系列讨论之三:终末期患者的尊严[J].中国医学伦理学,2018,31(1):28-34
[22]夏媛媛.知情同意与保护性医疗的冲突与联系[J].中国医学伦理学,2008,21(1):58-60
[23]杜治政.关于生命伦理学——伦理学道德观念面临的挑战[J].医学与哲学(A),1986,7(7):1-6
[24]胡东霞,李斯.生命神圣性与生命品质:走出生命伦理学困境[J].中国医学伦理学,2009,22(5):23-25
[25]王云岭,曹永福.现代医学背景下的生命观[J].科学与社会,2017(4):71-82
[2]国家卫生和计划生育委员会.国家卫生计生委办公厅关于印发安宁疗护实践指南(试行)的通知[EB/OL].[2017-02-09]. http://www. moh.gov. cn/yzygj/s3593/201702/83797c0261a94781b158dbd76666b717. shtml
[3] The 2015 Quality of Death Index[EB/OL].[2018-08-18]. https://www.basw.co.uk/system/files/resources/basw_94746-1_0.pdf
[4]陈万青,孙可欣,郑荣寿,等. 2014年中国分地区恶性肿瘤发病和死亡分析[J].中国肿瘤,2018,27(1):1-14
[5] Zou M,O’connor M,Peters L,et al. Palliative care in mainland China[J]. Asia Pacific Journal of Health Management,2013,8(1):9-13
[6] WHO definition of palliative care[EB/OL].[2018-08-18]. http://www.who.int/cancer/palliative/definition/en/
[7] National Institutes of Health. What are palliative care and hospice care?[EB/OL].[2018-12-03]. https://www.nia.nih.gov/health/what-are-palliative-care-and-hospice-carerequirement
[8]周玲君,沈伟,赵继军.癌症患者临终阶段症状特点及与生存期的关系[J].护理学杂志,2009,24(6):6-8
[9] Mh VE,Hochstenbach LM,Joosten EA,et al. Update on prevalence of pain in patients with cancer:systematic review and meta-analysis[J]. J Pain Symptom Manage,2016,51(6):1070-1090
[10] Teunissen SM,Wesker W,Kruitwagen C,et al. Symptom prevalence in patients with incurable cancer:a systematic review[J]. J Pain Symptom Manage,2007,34(1):94-104
[11] Ong WY,Yee CM,Lee A. Ethical dilemmas in the care of cancer patients near the end of life[J]. Singapore Med J,2012,53(1):11-16
[12] Turkoski BB. Home care and hospice ethics:using the code for nurses as a guide[J]. Home Healthc Nurse,2000,18(5):316-317
[13] Cheon J,Coyle N,Wiegand DL,et al. Ethical issues experienced by hospice and palliative nurses[J]. Journal of Hospice&Palliative Nursing,2015,17(1):14-15
[14] Chiu TY,Hu WY,Chen CY. Ethical dilemmas in palliative care:a study in Taiwan[J]. J Med Ethics,2000,26(5):353-357
[15]Daugherty CK. Examining ethical dilemmas as obstacles to hospice and palliative care for advanced cancer patients[J]. Cancer Invest,2004,22(1):123-131
[16]Mccabe MS,Coyle N. Ethical and legal issues in palliative care[J]. Semin Oncol Nurs,2014,30(4):287-295
[17]于虎,沈开金,敖其,等.急诊心肺复苏4年间变化趋势的单中心研究[J].中华危重病急救医学,2014(10):734-736
[18] Sehatzadeh S. Cardiopulmonary resuscitation in patients with terminal illness:an evidence-based analysis[J].Ont Health Technol Assess Ser,2014,14(15):1-38
[19]Kj?rstad OJ,Haugen DF. Cardiopulmonary resuscitation in palliative care cancer patients[J]. Tidsskr Nor Laegeforen,2013,133(4):417-421
[20] Granda-Cameron C,Houldin A. Concept analysis of good death in terminally ill patients[J]. Am J Hosp Palliat Care,2012,29(8):632-639
[21]张新庆,王云岭,韩跃红,等.“生命尊严”系列讨论之三:终末期患者的尊严[J].中国医学伦理学,2018,31(1):28-34
[22]夏媛媛.知情同意与保护性医疗的冲突与联系[J].中国医学伦理学,2008,21(1):58-60
[23]杜治政.关于生命伦理学——伦理学道德观念面临的挑战[J].医学与哲学(A),1986,7(7):1-6
[24]胡东霞,李斯.生命神圣性与生命品质:走出生命伦理学困境[J].中国医学伦理学,2009,22(5):23-25
[25]王云岭,曹永福.现代医学背景下的生命观[J].科学与社会,2017(4):71-82