Методички онкология / 6 курс / Студенты / 2
.docMINISTRY 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
Students Course VI
|
Theme 5. Palliative and symptomatic treatment |
|
Theme 6. Treatment of patients with disorders of alimentary canal |
|
Theme 7. Treatment of patients with disorders of the respiratory system |
Kharkiv 2012
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.
Ukraine's current system of so-called symptomatic treatment of severe patients no longer meet modern requirements and needs improvement. In practice it is usually reduced to a minimum in terms of treatment under the supervision of a doctor and the appointment of precinct narcotic analgesics if so concluding oncologist. In the worst moment of life the patient and his relatives remain alone with themselves and are often forced to seek help from friends or many "healers", which only deepens the patient's condition.
Meanwhile, palliative 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 care in Ukraine includes two main aspects: training of medical staff and a network of medical units to provide outpatient and inpatient care.
Palliative treatment - a comprehensive skilled medical care of the patient and his family members on stage controlling disease progression. Palliative treatment is an incurable cancer patients at the stage of controlling disease progression, and patients who suffered as a result of serious injury or no tumor pathology. Palliative care also includes elements of medical and social rehabilitation, aimed at supporting the best possible physical and mental activity of the patient at all stages of the disease.
Palliative treatment continues and shortens life, helps to perceive dying as a natural way of life, pozbavlyuye patient from pain and suffering, helps the patient and family support staff, provides a reasonable quality of life and a decent way out of it.
World experience shows that effective palliative 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 joint work .
In Ukraine, the main coordinating role in organizing and conducting palliative care given to District (family) doctor, who directly oversees patient and involves treatment, if necessary, specialists of other profiles. The decision to move from radical to palliative care is owed oncologists and taken collectively, based on a careful evaluation of the results followed by therapy and prognosis of the further development of the disease.
Exhaustion special features of anticancer therapy and start controlling disease progression demonstrates the need for the transition to purely palliative treatment aimed not to prolong life and to support its acceptable quality. Palliative treatment includes all the necessary types of medical care, the patient may be required at this stage, including: special (radiation therapy - as a method of pain relief with metastases to the bone, brain, soft tissue, chemotherapy - for pain relief or reduction of tumor ), surgical techniques (overlay Stom, necrectomy, drainage, immobilization, etc.), drug therapy, psychological aid to the patient, his family members and servicing.
In many countries, palliative care cancer patients available in specialized departments of oncology institutes and clinics (Australia, Germany,) or a service ambulatory care at home (USA, Italy, France, Finland). A classic institution of palliative care patients who are English hospice, 95% of patients who - is cancer. Hospice movement began in Britain in razvyvatysya 60 - 70 years The word "hospice" oznachaet translated from the Latin "strannopryymnыy home." Similar monastic houses to create ill pilgrims in the Middle Ages. The typical hospice includes hospital, clinic with day care or counseling service and medical care at home, in some cases - the educational and research departments. In day care, but medical procedures provided hairdressing services carried water treatment, etc. Created the conditions for the organization of joint spilkuvannya and leisure patients. This makes it possible to improve the psycho-emotional state of patients and prolong their stay at home, giving the rest of the family on daytime. With the deterioration of patients hospitalized.
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.
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.
Palliative therapy includes an arsenal of treatments that are used in various combinations in each case, depending on current needs. Features of the disease may, for example, require the use of emergency surgery: stenosis of the respiratory tract, dysphagia, obstruction of the gastrointestinal tract, urinary retention, etc. There may be indications for the use of radiation (with bone metastases) or chemotherapy (to reduce tumor mass).
Every time when choosing a treatment, we must be guided by the following considerations:
Treatment should be directed, even temporarily, but the improvement of the patient;
patient's condition allows for treatment without additional risk;
side effects of treatment can be avoided and they are safe;
patient agrees to the plan future treatment.
Discussion of the treatment plan must be collective, comprehensive and balanced, taking into account that the complications and side effects of treatment can minimize the desired result and only deepen the suffering of the patient. Therefore, in critical situations, rozhlyaduyuchy possibility of complex treatments, with doubts in a favorable conclusion, we must be guided by the principle of "do no harm" and leave the patient alone, abandoning heavy and useless attempts to extend its life.
The patient, if capable, has the full right to decide their fate, and to consent to treatment. Even if we do not agree with his decision, we can not do anything against the wishes of the patient or his relatives (in cases where the patient can not take an independent decision). In the categorical refusal of the patient from the treatment our duties remain the same - all possible methods to relieve the patient from suffering and help his family.
Literature:
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.