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Kharkiv National Medical University



on the methodical meeting Department of Oncology

Head of Department

MD, Professor VI Starikov

"30" August 2012



A methodical DEVELOPMENT

Students Course VI



Theme 8. Keeping of documentation in clinical oncology

Theme 9. Deontology in Oncology

Topic 10. Treatment of chronic pain syndromes










Kharkiv 2012

Ukraine is among the top ten countries with the highest population onkozahvoryuvanistyu annually are more than 180 000 patients with various malignancies, and accounting are about 750-800 thousand patients, many of which require different types of palliative care.

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

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.

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.

The basic principles of palliative care are: respect for life, the desire to do good, the priority of the interests of the patient; collegiality in decision-making.

Recognizing the inevitability of death, we believe that life is unique and strive to maintain it as long as it meets the interests and desires of the patient. At the same time, the physician has no moral or legal right to continue to torment, so you need to do everything possible to rid the patient of suffering and dying long. If physical and moral suffering of the patient unbearable and not amenable to correction, to discuss the introduction of a patient in sleep medication without pozbavlyuyuchy his life.

No matter how we tried to extend the patient's life, there comes a stage of human disease, when death is inevitable. Conducting resuscitation is justified only in cases where the patient can return to conscious life without suffering. In other cases, as it does not hurt the way out of life means desired freedom from suffering. The duties of a doctor is not keeping the patient's life at any cost, at some point need to let the patient die peacefully.

Attenuation of hope, indifference, apathy, refusal to eat - signs that the patient no longer resist and resigned to the inevitability of death. Resuscitation in such cases is hardly justified.

Due to the fact that many decisions in medicine are accepted on the basis of a more or less reasonable assumptions to avoid the errors are all important issues must be discussed collectively, with the participation of medical staff, the patient and his relatives. Moreover, experience shows that one can never exclude the possibility of improving the condition of the patient, if there is even the slightest precursors.

Everyone is experiencing severe and the more incurable illness differently. The range of possible psychological and emotional states of patients varied - it depends on the nature of personality and other psychological and social factors: a deep depression and despair, indifference and apathy, anger and resentment, peaceful reconciliation with imminent death, etc.

Loss of AI and awareness bezvyhidnoti leads to deep depression and mental exhaustion, which deepens the physical and mental suffering of the patient. Relatives also possessed despair and helplessness before nasuvayuchoyu trouble.

In this situation, the patient must be understanding and compassion that he felt abandoned and always felt care and attention. We must fully support the hope for possible enhancement while avoiding unrealistic promises that can only undermine patient by a doctor.

Caring for patients with severe combined with significant psycho-loads for relatives and staff. There may be a feeling of futility of their efforts, guilt and depression and as a result - the desire to avoid contact with patients. In such cases, you can understand that we terminally ill person who can not always cope with their emotions and needs our help. Our duty - to keep emotions and focus on the performance of their professional duties. It is unacceptable to enter into conflict with the patient and try to "convince" him. Correct, most delicately and kindly explain the causes of ill feelings, express their sympathy to distract the patient from serious thoughts, soothe and set up on a more optimistic note.

The patient should see that done everything necessary for his treatment, and he participates in the discussion of important issues. This helps to create a sense of ownership in a patient situation in which he found himself, and from a sense of futility pozbavlyuye.

Great importance is proper communication with patients, the aim of which:

     reassure the patient;

     convince him that everything possible is done to improve his condition, and he will be left without assistance;

     dispel feelings of undetermined;

     focus on the positive aspects of the patient and possible prospects of improvement;

     help in choosing the right solution for proper treatment and care.

The success and efficiency of communication with the patient is largely dependent on the manners and the ability to listen to the patient. The patient does not always, for various reasons, can implement in your family need to trust someone, share their experiences, discuss their personal, sometimes intimate problems.

Please create a comfortable environment for conversation, preferably alone. First you say hello (we can rukopotysnennyam), then learn about health, about the complaint. It is important to listen carefully to the patient, to give him the opportunity to speak from time to time directing the conversation in the right direction suggestive questions. Should be avoided in conversation use medical terminology and be sure that the patient understood everything correctly. The relationship between doctor and patient is based on trust, so you should try not to say obvious lie and give bezhruntivnyh promises.

Most of all patients interested in information about his illness and the prospect of recovery. This part of the conversation with the patient is the most difficult for the doctor. To say or not to tell the patient the truth?

This is not a simple issue and there are opposite opinions about this. Of course, every patient has the right to know the truth, but no one can predict what will be the reaction to a serious message, which often leads the patient to complete despair.

So should we deprive a person of last resort only in order that she should know the truth?

In fact, there is only one good reason to open the patient the seriousness of his situation - a refusal of treatment because the patient does not understand the gravity of their situation. But in such cases it is always possible to avoid excessive injury, protecting the psyche of the patient.

Firstly, you can do without direct declaration that the patients with malignant tumor, and without such terms as "cancer," "sarcoma" etc., replacing them, for example, the expression "precancerous process", "proliferation" or simply - "tumor." The patient can be explained that the delay in treatment will ozloyakisnennya or of adverse complications to deal with that will be much harder. In most cases, such an explanation is enough to ensure that the patient has made ​​the right decision.

Secondly, you need to dispense information, depending on patient response, report it gradually. If you see that the patient is pleased with your words and do not require further explanation - stop there. Do not impose the patient the truth and, moreover, contrary to his wishes.

Finally, thirdly, you must use influence on the patient's relatives informed and fully understand the essence of the situation. With relatives can discuss all the details of the future treatment prospects and prognosis. Thus, in respect of the relatives should enjoy the same ethical principles, chief among them - "do no harm".

Help family is an integral part of patient care and one of the important tasks of palliative care. Feeling that the patient receives the best possible care, helping relatives move lehche spitkavshe their grief and helps them create around a patient quieter and more favorable atmosphere.

Discussing with relatives complex issues need to be sure that they share the point of view of a doctor and will influence the patient in the right direction. You must notify relatives of modern methods of treatment of patients with malignant tumors and convince harm the use of so-called "alternative therapies" totally ineffective and even dangerous for the patient. It is advisable to pre-check that their response will be adequate and they do not "Transfer" all patients, but in their distorted interpretation. If not properly discuss all issues with the patient, of course, subject to these deontological principles.

A very important point is to keep the patient's sense of hope that helps mobilize the mental strength and calm. And the patient and his relatives in need of hope, as the goal, the achievement of which gives substance to their lives and can deal with hopelessness and despair.

The patient loses hope when suffering from pain or other symptoms of disease, feels abandonment, isolation and uselessness of his existence. At the same time, hope remains, if not effectively control pain and other serious symptoms, and patient care experiences and their necessity.

It is important to maintain hope is to set short-term goals that allow you to create the illusion of struggle and put substance of life of the patient and his relatives. Goals should be realistic and achievable, aimed at combating certain symptoms or simple solution to everyday problems. They are adjusted by changing the way the patient. You do not have to focus on the deteriorating condition of the patient, it is better to say that it is influenced by the treatment, etc.

Saving Hope - a very important point that defines the spiritual state of man, it can and should turn to the religious beliefs of the patient. It is possible to speak with a patient who has no solid religious beliefs. The most important thing for a believer out of life does not mean divorce forever remains the last hope - at a future meeting in another world and it helps the patient and family to keep his composure during the loss.

The last days in the life of the patient are important. Realizing that nothing can save the patient, we need to focus on to minimize its physical and mental suffering and help the family move weight loss.

The main signs of the onset of the final stage of the disease is a progressive deterioration, impaired consciousness and disorientation, lethargy, drowsiness development, lack of appetite and desire to make a dish. According to the Oxford textbook of palliative medicine, the most frequent symptoms of the terminal stage of the disease:

     noisy, humid breath, tachypnea - 56%;

     urinary system - 53%;

     increased pain - 51%;

     anxiety and mobile activity - 42%;

     cough, shortness of breath - 22%;

     nausea and vomiting - 14%;

     sweating - 14%;

     muscle twitching and clonic convulsions - 12%;

     disorientation and confusion - 9%.

It is important to determine the basis of clinical onset of the process of extinction of vital functions, appropriate therapy, to ensure proper care and inform the relatives of the patient about his soon demise.

Therapy and nursing in this stage of the disease is to provide peace and comfort as possible, adequate anesthesia, sedation appointment, eliminating burdensome symptoms. The question of whether to tell or not to tell the patient about his position remains open. Perhaps more correctly out of the particular situation and if it is not extreme need hardly feasible even in the last hours pozbavlyuvaty patient, even illusory, but hope and complicate his state of mind.



B ondar G. B., B and itenko. C., P opovych Oh. Yu P aliatyvna medical care

The manual for students of V - VI courses, medical interns and family physicians., D onetsk 2004. - 108s.

Anesthesia with rake - Geneva: Vsemyrnaya organization of Health, 1989.-74 p.

Anesthesia with rake and pallyatyvnoe Treatment: Report committee of experts WHO. - Geneva, 1992.-76 p.



Methodological development was      by    MD, assistant Muzhychuk O.

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