MINISTRY OF HEALTH OF UKRAINE

Kharkiv National Medical University

 

Approved

on the methodical meeting Department of Oncology

Head of Department

MD, Professor VI Starikov

"30" August 2012

 

 

A methodical development For independent work of students

 

Course 6

Faculty of Medicine (specialty "General Medicine", "Pediatrics", "Prophylactic medicine")

Study Subject: Oncology

 

Topic	Number of hrs
Theme 5. Palliative and symptomatic treatment	2
Theme 6. Treatment of patients with disorders of alimentary canal	2
Theme 7. Treatment of patients with disorders of the respiratory system	2

 

 

 

Kharkiv 2012

 

Background.

Palliative and symptomatic medicine in many European countries - is developed healthcare industry, whose main objective - providing, maintaining and improving the quality of life for seriously ill, disabled persons and their families through all the arsenal of modern medicine.

Improving palliative and symptomatic care in Ukraine includes two main aspects: training of medical staff and a network of medical units to provide outpatient and inpatient care.

Despite the apparent success of modern oncology, most cancer patients still die as a result of disease progression, so the problem of palliative and symptomatic care remains relevant throughout the world.

 

Study objective: Deepen the theoretical and practical knowledge of students on palliative and symptomatic treatment of cancer patients.

Know:

1.       Features of the development of malignant tumors.

2.       Analyze the causes of abandonment of malignant tumors.

3.     understanding of the concept and principles of palliative care;

4.     ability to properly assess the clinical manifestations of the disease in its progression and justify the transition from radical to palliative care;

5.     ability to apply basic methods of instrumental and pharmacological therapy of pain and other complications of the disease;

6.     knowledge of psychological, ethical, social and religious aspects of palliative medicine;

7.     ability to assess the quality of life of patients and to determine the most important factors that influence it.

Be able to:

Conduct review of cancer.

Absorb the history and analyze it.

With astosovuvaty basic methods instrumentals tion and pharmacological therapy pain

Oh tsinyuvaty quality of life of patients

Analyze the causes of abandonment of malignant tumors.

Palliative treatment - complex anticancer treatments, and to result in short-term remission. That palliative treatment includes the same anticancer treatments like surgery, radiation therapy, drug therapy. Palliative treatment is the inability of radical treatment of cancer patients ..

World experience shows that effective palliative and symptomatic care is based on the collective work of doctors (oncologist, therapist, psychotherapist, algology, nurses, etc.)., Social workers, relatives and friends of the patient, priests and a high level of consistency in their working together.

Exhaustion special features of anticancer therapy and start controlling the progression of the disease indicates the need to move to a purely symptomatic treatment aimed not to prolong life and to support its acceptable quality. symptomatic therapy is the correction of certain secondary tumor symptoms. symptomatic therapy to the tumor is not affected. symptomatic treatment includes all the necessary types of care that may be needed to the patient at this stage, including: special (radiation therapy - as a method of pain relief with metastases to the bone, brain, soft tissue, chemotherapy - for pain or reducing tumor ), surgical techniques (overlay Stom, necrectomy, drainage, immobilization, etc.), drug therapy, psychological aid to the patient, his family members and servicing.

The main goal of palliative care - support the highest possible level of quality of life for the patient and his family. The concept of "quality of life" purely personal - a subjective assessment of their current state of the patient, taking into account various factors for this personality are essential. It is obvious that every patient differently understands the meaning of "quality of life" and it is his inalienable right. The level of the quality of life is determined by how real the possibility of patient coincide with his wishes, hopes and dreams. When stationary, the terminally ill focuses on full life of a healthy person, the gap between the desired and reality is too large and the quality of life seems low. On the contrary, in the same case, the quality of life can be considered acceptable, judging from the fact that the patient is not suffering from pain, capable of mental activity, communication and so on. Thus, the assessment of quality of life is determined, on the one hand, the effectiveness of palliative care, on the other hand, depends on a calm, balanced assessment of patients with their actual capabilities. So help the patient in forming adequate assessment of social values ​​and priorities is an important task of palliative medicine.

To assess the quality of life using different methods: by Karnavskym, ECOG and others. On the recommendation of IASP in palliative medicine for evaluation of quality of life appropriate to use different criteria that allow you to evaluate all aspects of a patient's life, such as: overall physical condition and functional activity, the possibility of self and environment in the family, sociability and social adaptation, spirituality and professional activities , evaluation of treatment results and plans for the future; sexual satisfaction etc.

Palliative medicine is aimed at solving 'Liabilities challenges a patient who is in a terminal state. However, one must keep in mind that the concept of terminal period, its signs and duration can be very different. In practice, palliative medicine terminal condition viewed as a period of time during which develops progressive disorder and controlling basic vital functions of the patient, which inevitably leads to his death. Clearly, in various pathologies clinical presentation and duration of the terminal will be different, perhaps the most common criterion for them is ineffective therapies and the following features:

     pervasive disorders of the systems that support the life of the body;

     progressive nature of violations life support systems;

     probably justified pessimistic forecasts;

     violation of integrative functions of the central nervous system.

In deciding on the transition to palliative care patient physician governed by the provisions of Venice Declaration, whose main provisions say:

"1. During treatment the doctor commitments, if possible, to alleviate the suffering of the patient, always guided by his interests.

2. Exceptions to the above principle in paragraph 1 are not permitted, even in the case of incurable diseases and distortion.

3. Exceptions to the above principle in paragraph 1 are not considered the following cases:

3.1. The doctor should not continue suffering dying, stopping at his request that if the patient is unconscious - a request by relatives, a treatment that can only delay the onset of the inevitable end. Refusal of treatment does not relieve the physician of obligation 'to help dying communication, appointing drugs that facilitate suffering.

3.2. The physician must refrain from the use of unconventional methods of therapy that, in his opinion, will not bring real benefit to the patient.

3.3. Your doctor can artificially maintain vital functions deceased to preserve organs for transplantation, provided that the country's laws do not prohibit this, there is agreement that given to the onset of terminal patients, or after ascertaining the fact of death - his legal representative and death confirmed by a doctor right not linked to or from the treatment of the dying, no treatment-potential recipient. Doctors who assisted dying must not depend neither on the potential recipient, nor the doctors who treated him "(adopted on 35 World Medical Assembly in October 1983.).

Palliative medicine is aimed at solving 'Liabilities those problems inkurabelnoho patient, not the solution' is associated medical, psychological or social factors that hurt his psyche. Medical problems include anti-pain, symptom control, organization of patient care. Social problems related to environment and quality of life issues, logistics and so on.

Most difficult in some cases are psychological problems. Most researchers consider n 'five basic types of psychological reactions that occur in patients inkurabelnyh: shock, denial stage, the stage of aggression, depression stage and the stage of reconciliation.

Experiences phase of shock, panic, despair - the most difficult and painful not only for the patient but for the family and medical staff. In some cases, the situation is difficult to predict the strongest stress can cause the development of reactive psychosis, accompanied by excitement or stupor. In such cases, appropriate prophylactic neuroleptic or antidepressant drugs and qualified psychotherapeutic assistance.

In the phase of denial crisis of feeling displaced in the subconscious, although it is in experiences. With 'thoughts are saving a possible medical error, hope for a wonderful healing and favorable end. However, the psychological symptoms predominate image from ­ tea experience death, danger, sad, tragic dreams, hallucinations.

Phase aggression develops against the backdrop of recognizing the inevitability of the end and find the causes and perpetrators of this. Aggression often m and skuye own can be dangerous for the patient, which can not be left so as to prevent suicide. In this phase, aggression, anger, protest and hatred can be directed to surround and heavy obligation 'Call of medical staff - take this blow over and try d' yakshyty him for as long as emotions begin to wane.

Phase depression experienced by patients as deep inner feelings of sadness, guilt, regret, farewell to the world. Rapid expression of emotion varies reticence. In this phase, the most feasible seems silent participation and silent sympathy. If necessary, show prescribing of antidepressants.

The final stage is reconciliation with fate when the patient understands and accepts the inevitability of the end of it. In this phase occurs revaluation of life values ​​and the meaning of life, of 'is the end of life's journey of understanding, peace, hope for eternal life in another world.

It should be noted that the presented scheme is to some extent arbitrary. In real life listed stage can change place or even be absent, because the compulsory condition for psychological assistance is qualified psychotherapeutic monitoring of patients.

Materials control baseline (rising levels) of students:

. Quiz:

Score skarzhen and history of cancer patients.

Rules students in oncology clinic. Supervision of patients.

Indications for the appointment of palliative care cancer patients

Indications for appointment symptomatic treatment of cancer patients.

Correction inkurabelnoho psychological state of the patient.

Principles of ethics in oncology. Types of higher nervous activity and response of patients with cancer.

Tactics doctor in relation to cancer patients.

Motives failure patients on treatment. The ratio of people who recovered from cancer, with patients with long standing forms of malignant tumors.

Information relative. Kantserofobiya. Euthanasia. Calling consultant.

 

T estovi task

Physician Oncologist:

- Must provide treatment regardless of the wishes of the patient and good for him;

- Does not have to continue suffering dying, stopping at his request that if the patient is unconscious - a request by relatives, a treatment that can only extend the inevitable end *;

must provide treatment to save the patient's organs for future transplants;

- Should not treat the terminally ill

Symptomatic treatment is:

Radiation and chemotherapy is the inability to perform radical surgery;

Surgery to remove part of the tumor;

Removal of the tumor in the presence of unresectable metastases;

Withdrawal symptoms secondary tumor *.

Palliative treatment is:

Withdrawal symptoms secondary tumor;

Anticancer therapy, which aims to brief remission *;

Appointment of narcotic analgesics.

Caring for cancer patients

clinical case studies (Correct answers are marked "*")

Task 1. to general hospitals enrolled patient B. '56 complaining of dysphagia, epigastric discomfort, significant pohudinnya, general weakness, headache. In FEHDS in abdominal esophagus detected tumor narrows its lumen to 0.5 cm By stomach login failed. Biopsy - cancer of the esophagus. With ultrasound revealed multiple metastases to the liver. CT - metastases in the mediastinum and in the tissue of the brain. Which therapeutic approach?

A. Palliative radiotherapy, chemotherapy.

B. * Symptomatic operation - laying gastrostomy.

C. Appointment of narcotic analgesics.

D. Removal of the tumor.

Task 2. Patient entered the clinic N., 53, with neglected tumor of the right breast. Tumor size 13h15 mm, bleeding in the right axillary area - not driven conglomerate. Vnutrishkiryany Multiple metastases. Which therapeutic approach?

A. Radical mastektamiya.

B. * Palliative sanitary mamektomiya followed himiohormonoterapiyeyu.

C. Appointment of narcotic analgesics.

D. Palliative radiotherapy and chemotherapy.