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JAMA：癌症患者的临终关怀——积极治疗不一定好

2016-01-26 MedSci MedSci原创

晚期癌症临终关怀ICU死亡护理
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高等级癌症患者在死亡之前接受着越来越多的积极治疗，尽管认为这反应了低质量护理的担忧逐渐增多。 研究目的是为了评估临终前积极治疗与丧失亲人的家庭成员对临终护理质量的观点和病人的治疗目标达成之间的联系。 在癌症治疗结果研究和生存率研究中（多方位、前瞻性、观察性研究），采访了1146位患有高等级肺癌或直肠癌的医保病人的家庭成员，这些病人在2011年底去世(中位数是死后144.5天,四分位范围

高级别癌症患者在死亡之前接受着越来越多的积极治疗，尽管认为这反应了低质量护理的担忧逐渐增多。

研究目的是为了评估临终前积极治疗与丧失亲人的家庭成员对临终护理质量的观点和病人的治疗目标达成之间的联系。

在癌症治疗结果研究和生存率研究中（多方位、前瞻性、观察性研究），采访了1146位患有高等级肺癌或直肠癌的医保病人的家属，这些病人在2011年底去世(中位数是死后144.5天,四分位范围85.0 - -551.0天)。

暴露因素：基于声明的积极的临终治疗（如，重症监护ICU，或在生命的最后一个月多次住院或急诊就诊；化疗小于每周2次而死亡的；未接受临终关怀或小于3天临终关怀服务；住院期间死亡的）。

结局：1146名癌症患者(平均年龄76.0岁(四分位范围65.0 - -87.0岁),55.8%的男性),亲属报道优质的临终关怀为51.3%。家庭成员报道优质的临终关怀的病人通常接受临终关怀时间超过3天(58.8%[352/599])，比那些没有接受临终关怀或接受3天或更少时间(43.1%[236/547])(调整差异,16.5(95%可信区间,10.7至22.4))的病人要好。相反的是，进入ICU治疗的病人（在30天内死亡）的亲属报道的优质的临终关怀(45.0% [68/151])比那些没有进入ICU的病人要少(52.3% [520/995])。类似的，在医院死亡的病人家属报道的优质护理(42.2% [194/460])比不在医院死亡的患者家属报告的(57.4% [394/686])要少。没有接受临终关怀或少于3天临终关怀的患者(57.4% [394/686])比那些接受临终关怀超过3天的患者(72.8% [287/394]) 更不可能自己选择想要的离开地点。

结论：在有医保的死于肺癌或直肠癌的老年患者中，家庭成员认为早些进行临终关怀，在死前30天避免进入ICU和不在医院里死亡是比较好的临终护理。这些发现支持了高级护理计划与患者喜好的一致性。

原始出处：

Alexi A. Wright, MD, MPH; Nancy L. Keating,et al,Family Perspectives on Aggressive Cancer Care Near the End of Life.JAMA.2015 

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createdTime=Tue Feb 02 17:28:00 CST 2016, time=2016-02-02, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1570809, encodeId=71ca15e08090f, content=<a href='/topic/show?id=ace42309edc' target=_blank style='color:#2F92EE;'>#临终#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=30, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=23097, encryptionId=ace42309edc, topicName=临终)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=d35015719835, createdName=bbjsj_1984, createdTime=Thu Jan 28 05:09:00 CST 2016, time=2016-01-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1353219, encodeId=fa411353219d2, content=<a href='/topic/show?id=33292309808' target=_blank style='color:#2F92EE;'>#临终关怀#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=39, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=23098, encryptionId=33292309808, topicName=临终关怀)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=4c37265, createdName=zhaojie88, createdTime=Thu Jan 28 05:09:00 CST 2016, time=2016-01-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1289487, encodeId=3363128948e8a, content=<a href='/topic/show?id=cbb8e1356f7' target=_blank style='color:#2F92EE;'>#癌症患者#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=71356, encryptionId=cbb8e1356f7, topicName=癌症患者)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=10ba218, createdName=zgwhgch, createdTime=Thu Jan 28 05:09:00 CST 2016, time=2016-01-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=61404, encodeId=15ec61404f7, content=值得推广, beContent=null, objectType=article, channel=null, level=null, likeNumber=133, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=4bfa83595, createdName=jetleo, createdTime=Wed Jan 27 23:04:00 CST 2016, time=2016-01-27, status=1, ipAttribution=)]
    2016-02-19 英子-sci

    赞

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  2. 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    2016-02-11 1de4921fm57(暂无匿称)

    说的很对

    0

  3. 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topicName=临终关怀)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=4c37265, createdName=zhaojie88, createdTime=Thu Jan 28 05:09:00 CST 2016, time=2016-01-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1289487, encodeId=3363128948e8a, content=<a href='/topic/show?id=cbb8e1356f7' target=_blank style='color:#2F92EE;'>#癌症患者#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=71356, encryptionId=cbb8e1356f7, topicName=癌症患者)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=10ba218, createdName=zgwhgch, createdTime=Thu Jan 28 05:09:00 CST 2016, time=2016-01-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=61404, encodeId=15ec61404f7, content=值得推广, beContent=null, objectType=article, channel=null, level=null, likeNumber=133, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=4bfa83595, createdName=jetleo, createdTime=Wed Jan 27 23:04:00 CST 2016, time=2016-01-27, status=1, ipAttribution=)]
    2016-02-02 收获你的美

    收藏

    0

  4. 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beContent=null, objectType=article, channel=null, level=null, likeNumber=137, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/oLAjfB7s1ib06iaV3D9Tg5KwlM29ic8TDJMJOiarryMIZZhTjXxyRT9lffSWpWWcWojnL7ibJwcOn99ayict8FJ9ICYmNh9swD6R4E/0, createdBy=196f1683049, createdName=收获你的美, createdTime=Tue Feb 02 17:30:00 CST 2016, time=2016-02-02, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=62845, encodeId=2a746284571, content=可以考虑推广, beContent=null, objectType=article, channel=null, level=null, likeNumber=111, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/oLAjfB7s1ib06iaV3D9Tg5KwlM29ic8TDJMJOiarryMIZZhTjXxyRT9lffSWpWWcWojnL7ibJwcOn99ayict8FJ9ICYmNh9swD6R4E/0, createdBy=196f1683049, createdName=收获你的美, createdTime=Tue Feb 02 17:29:00 CST 2016, time=2016-02-02, status=1, ipAttribution=), 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topicName=临终关怀)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=4c37265, createdName=zhaojie88, createdTime=Thu Jan 28 05:09:00 CST 2016, time=2016-01-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1289487, encodeId=3363128948e8a, content=<a href='/topic/show?id=cbb8e1356f7' target=_blank style='color:#2F92EE;'>#癌症患者#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=71356, encryptionId=cbb8e1356f7, topicName=癌症患者)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=10ba218, createdName=zgwhgch, createdTime=Thu Jan 28 05:09:00 CST 2016, time=2016-01-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=61404, encodeId=15ec61404f7, content=值得推广, beContent=null, objectType=article, channel=null, level=null, likeNumber=133, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=4bfa83595, createdName=jetleo, createdTime=Wed Jan 27 23:04:00 CST 2016, time=2016-01-27, status=1, ipAttribution=)]
    2016-02-02 收获你的美

    可以考虑推广

    0

  5. 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topicName=临终关怀)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=4c37265, createdName=zhaojie88, createdTime=Thu Jan 28 05:09:00 CST 2016, time=2016-01-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1289487, encodeId=3363128948e8a, content=<a href='/topic/show?id=cbb8e1356f7' target=_blank style='color:#2F92EE;'>#癌症患者#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=71356, encryptionId=cbb8e1356f7, topicName=癌症患者)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=10ba218, createdName=zgwhgch, createdTime=Thu Jan 28 05:09:00 CST 2016, time=2016-01-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=61404, encodeId=15ec61404f7, content=值得推广, beContent=null, objectType=article, channel=null, level=null, likeNumber=133, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=4bfa83595, createdName=jetleo, createdTime=Wed Jan 27 23:04:00 CST 2016, time=2016-01-27, status=1, ipAttribution=)]
    2016-02-02 收获你的美

    赞

    0

  6. 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createdTime=Tue Feb 02 17:28:00 CST 2016, time=2016-02-02, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1570809, encodeId=71ca15e08090f, content=<a href='/topic/show?id=ace42309edc' target=_blank style='color:#2F92EE;'>#临终#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=30, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=23097, encryptionId=ace42309edc, topicName=临终)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=d35015719835, createdName=bbjsj_1984, createdTime=Thu Jan 28 05:09:00 CST 2016, time=2016-01-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1353219, encodeId=fa411353219d2, content=<a href='/topic/show?id=33292309808' target=_blank style='color:#2F92EE;'>#临终关怀#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=39, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=23098, encryptionId=33292309808, topicName=临终关怀)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=4c37265, createdName=zhaojie88, createdTime=Thu Jan 28 05:09:00 CST 2016, time=2016-01-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1289487, encodeId=3363128948e8a, content=<a href='/topic/show?id=cbb8e1356f7' target=_blank style='color:#2F92EE;'>#癌症患者#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=71356, encryptionId=cbb8e1356f7, topicName=癌症患者)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=10ba218, createdName=zgwhgch, createdTime=Thu Jan 28 05:09:00 CST 2016, time=2016-01-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=61404, encodeId=15ec61404f7, content=值得推广, beContent=null, objectType=article, channel=null, level=null, likeNumber=133, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=4bfa83595, createdName=jetleo, createdTime=Wed Jan 27 23:04:00 CST 2016, time=2016-01-27, status=1, ipAttribution=)]
    2016-02-02 收获你的美

    有道理

    0

  7. [GetPortalCommentsPageByObjectIdResponse(id=64842, encodeId=38b664842d5, content=赞, beContent=null, objectType=article, channel=null, level=null, likeNumber=117, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=5c361683364, createdName=英子-sci, createdTime=Fri Feb 19 23:26:00 CST 2016, time=2016-02-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=63989, encodeId=6b416398956, content=说的很对, beContent=null, objectType=article, channel=null, level=null, likeNumber=126, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160613/IMG575D9886B86721544.jpg, createdBy=07961686486, createdName=1de4921fm57(暂无匿称), createdTime=Thu Feb 11 17:14:00 CST 2016, time=2016-02-11, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=62847, encodeId=83a46284e69, content=收藏, 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GetPortalCommentsPageByObjectIdResponse(id=62846, encodeId=ab55628468f, content=赞, beContent=null, objectType=article, channel=null, level=null, likeNumber=131, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/oLAjfB7s1ib06iaV3D9Tg5KwlM29ic8TDJMJOiarryMIZZhTjXxyRT9lffSWpWWcWojnL7ibJwcOn99ayict8FJ9ICYmNh9swD6R4E/0, createdBy=196f1683049, createdName=收获你的美, createdTime=Tue Feb 02 17:29:00 CST 2016, time=2016-02-02, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=62844, encodeId=aa4262844ca, content=有道理, beContent=null, objectType=article, channel=null, level=null, likeNumber=78, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/oLAjfB7s1ib06iaV3D9Tg5KwlM29ic8TDJMJOiarryMIZZhTjXxyRT9lffSWpWWcWojnL7ibJwcOn99ayict8FJ9ICYmNh9swD6R4E/0, createdBy=196f1683049, createdName=收获你的美, createdTime=Tue Feb 02 17:28:00 CST 2016, time=2016-02-02, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1570809, encodeId=71ca15e08090f, content=<a href='/topic/show?id=ace42309edc' target=_blank style='color:#2F92EE;'>#临终#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=30, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=23097, encryptionId=ace42309edc, topicName=临终)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=d35015719835, createdName=bbjsj_1984, createdTime=Thu Jan 28 05:09:00 CST 2016, time=2016-01-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1353219, encodeId=fa411353219d2, content=<a href='/topic/show?id=33292309808' target=_blank style='color:#2F92EE;'>#临终关怀#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=39, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=23098, encryptionId=33292309808, topicName=临终关怀)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=4c37265, createdName=zhaojie88, createdTime=Thu Jan 28 05:09:00 CST 2016, time=2016-01-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1289487, encodeId=3363128948e8a, content=<a href='/topic/show?id=cbb8e1356f7' target=_blank style='color:#2F92EE;'>#癌症患者#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=71356, encryptionId=cbb8e1356f7, topicName=癌症患者)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=10ba218, createdName=zgwhgch, createdTime=Thu Jan 28 05:09:00 CST 2016, time=2016-01-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=61404, encodeId=15ec61404f7, content=值得推广, beContent=null, objectType=article, channel=null, level=null, likeNumber=133, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=4bfa83595, createdName=jetleo, createdTime=Wed Jan 27 23:04:00 CST 2016, time=2016-01-27, status=1, ipAttribution=)]
    2016-01-28 bbjsj_1984

    #临终#

    0

  8. 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createdTime=Tue Feb 02 17:28:00 CST 2016, time=2016-02-02, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1570809, encodeId=71ca15e08090f, content=<a href='/topic/show?id=ace42309edc' target=_blank style='color:#2F92EE;'>#临终#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=30, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=23097, encryptionId=ace42309edc, topicName=临终)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=d35015719835, createdName=bbjsj_1984, createdTime=Thu Jan 28 05:09:00 CST 2016, time=2016-01-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1353219, encodeId=fa411353219d2, content=<a href='/topic/show?id=33292309808' target=_blank style='color:#2F92EE;'>#临终关怀#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=39, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=23098, encryptionId=33292309808, topicName=临终关怀)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=4c37265, createdName=zhaojie88, createdTime=Thu Jan 28 05:09:00 CST 2016, time=2016-01-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1289487, encodeId=3363128948e8a, content=<a href='/topic/show?id=cbb8e1356f7' target=_blank style='color:#2F92EE;'>#癌症患者#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=71356, encryptionId=cbb8e1356f7, topicName=癌症患者)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=10ba218, createdName=zgwhgch, createdTime=Thu Jan 28 05:09:00 CST 2016, time=2016-01-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=61404, encodeId=15ec61404f7, content=值得推广, beContent=null, objectType=article, channel=null, level=null, likeNumber=133, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=4bfa83595, createdName=jetleo, createdTime=Wed Jan 27 23:04:00 CST 2016, time=2016-01-27, status=1, ipAttribution=)]
    2016-01-28 zhaojie88

    #临终关怀#

    0

  9. 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topicName=临终关怀)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=4c37265, createdName=zhaojie88, createdTime=Thu Jan 28 05:09:00 CST 2016, time=2016-01-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1289487, encodeId=3363128948e8a, content=<a href='/topic/show?id=cbb8e1356f7' target=_blank style='color:#2F92EE;'>#癌症患者#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=71356, encryptionId=cbb8e1356f7, topicName=癌症患者)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=10ba218, createdName=zgwhgch, createdTime=Thu Jan 28 05:09:00 CST 2016, time=2016-01-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=61404, encodeId=15ec61404f7, content=值得推广, beContent=null, objectType=article, channel=null, level=null, likeNumber=133, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=4bfa83595, createdName=jetleo, createdTime=Wed Jan 27 23:04:00 CST 2016, time=2016-01-27, status=1, ipAttribution=)]
    2016-01-28 zgwhgch

    #癌症患者#

    0

  10. 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topicName=临终关怀)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=4c37265, createdName=zhaojie88, createdTime=Thu Jan 28 05:09:00 CST 2016, time=2016-01-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1289487, encodeId=3363128948e8a, content=<a href='/topic/show?id=cbb8e1356f7' target=_blank style='color:#2F92EE;'>#癌症患者#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=71356, encryptionId=cbb8e1356f7, topicName=癌症患者)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=10ba218, createdName=zgwhgch, createdTime=Thu Jan 28 05:09:00 CST 2016, time=2016-01-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=61404, encodeId=15ec61404f7, content=值得推广, beContent=null, objectType=article, channel=null, level=null, likeNumber=133, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=4bfa83595, createdName=jetleo, createdTime=Wed Jan 27 23:04:00 CST 2016, time=2016-01-27, status=1, ipAttribution=)]
    2016-01-27 jetleo

    值得推广

    0

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