My Draft Book for HARRISON INTERNAL MEDICINE

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My Draft Book for HARRISON INTERNAL MEDICINE

chapter 1 to 8 is here--- in the following link
http://www.dxy.cn/bbs/post/view? ... amp;tpg=1&age=0

finished them one chapter daily

[ 本帖最后由 zhangheng1020 于 2006-3-8 15:16 编辑 ]

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[ 本帖最后由 zhangheng1020 于 2006-3-6 22:52 编辑 ]

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9
Palliative and End-of-Life Care
Ezekiel J. Emanuel
Linda L. Emanuel
EPIDEMIOLOGY
In 2000, 2,403,351 people died in the United States (Table 9-1). Over 70% of all deaths occur in people >65 years of age. The epidemiology of mortality is similar in most developed countries; cardiovascular diseases and cancer are the predominant killers, a marked change since 1900, when heart disease caused ~8% of all deaths and cancer accounted for <4% of all deaths. In 2000, AIDS accounted for <1% of all deaths, although among those aged 35 to 44, it remains a leading cause of death.

While precise statistics are not available, it is estimated that in developed countries ~70% of all deaths are preceded by a disease or condition such that it is reasonable to plan for dying in the foreseeable future. Cancer has served as the paradigm for terminal care, but it is not the only type of illness with a recognizable and predictable terminal phase. Since congestive heart failure, chronic obstructive pulmonary
P.54
disease (COPD), chronic liver failure, and many other conditions have recognizable terminal phases, a systematic approach to end-of-life care should be part of all medical specialties. Many patients with advanced illness can also benefit from palliative care long before the terminal phases of their illnesses.
Over the past few decades in the United States, a significant change in the site of death has occurred that coincides with patient and family preferences. Nearly 60% of Americans died as inpatients in hospitals in 1980. By 2000, the trend was reversing, with ~40% of Americans dying as hospital inpatients (Fig. 9-1). This shift has been most dramatic for people dying from cancer and COPD and for younger and very old individuals. In the past decade, it is associated with the increased use of hospice care; in 2000, ~20% of all decedents in the United States received such care. Cancer patients currently constitute >70% of hospice users, with 33 to 50% of all terminal cancer patients receiving hospice care. About 90% of patients receiving hospice care die out of the hospital. Consequently, providing optimal palliative and end-of-life care requires ensuring appropriate services in a variety of settings, including noninstitutional settings.

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HOSPICE AND THE PALLIATIVE CARE FRAMEWORK
Central to this type of care is an interdisciplinary team approach that typically encompasses pain and symptom management, spiritual and psychological care for the patient, and support for family caregivers.
Terminally ill patients have a wide variety of advanced diseases, often with multiple symptoms demanding relief, and require noninvasive therapeutic regimens to be delivered in a commodious care setting. Fundamental to ensuring quality palliative and end-of-life care is a focus on four broad domains: (1) physical symptoms; (2) mental or psychological symptoms; (3) social needs that include interpersonal relationships, caregiving, and economic concerns; and (4) existential or spiritual needs.
A whole-person assessment screens for and evaluates needs in each of these four domains. Goals for care are established in discussion with the patient and/or family based on the assessment in each of these domains. Interventions are aimed at improving or managing symptoms and needs. While physicians are responsible for certain especially technical interventions, and for coordinating the interventions, they cannot be responsible for providing all of them. Since failing to address any one of the domains is likely to preclude a good death, a well coordinated, effectively communicating interdisciplinary team takes on special importance in end-of-life care.

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Whole-Person Assessment
Standardized methods for conducting a whole-person assessment focus on evaluating the patient's condition in all four domains affected by illness: physical, mental, social, and spiritual. The assessment of physical and mental symptoms should follow a modified version of the traditional medical history and physical examination that emphasizes symptoms. Questions should aim at elucidating symptoms but also discerning sources of suffering and how much these symptoms interfere with the patient's life. Standardized assessment questions are available from scales such as the Memorial Symptom Assessment Scale. Using such scales ensures that the assessment is comprehensive and does not just focus on pain and a few other physical symptoms. Invasive tests are best avoided in end-of-life care, and even minimally invasive tests should be carefully evaluated for their benefit-to-burden ratio for the patient. Aspects of the physical examination that are uncomfortable and unlikely to yield useful information can also be omitted.
Regarding social needs, health care providers should assess the status of important relationships, financial burdens, care-giving needs, and access to medical care. Relevant questions will include: How often is there someone to feel close to? How much help do you need with things like getting meals or getting around? How much trouble do you have getting the medical care you need? In the area of existential needs, providers should assess distress and the patient's sense of being emotionally and existentially settled and of finding purpose or meaning. Helpful assessment questions can include: How much are you able to find meaning since your illness began? In addition, it can be helpful to ask about how well the patient perceives his or her care to be: How much do you feel your doctors and nurses respect you? How clear is the information from us about what to expect regarding your illness? How much do you feel that the medical care you are getting fits with your goals? If concern is detected in any of these areas, deeper evaluative questions are warranted

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Communication
Foremost is to ensure empathetic and effective communication. When an illness is life-threatening, there are many emotionally charged and potentially conflict-creating moments, collectively called “bad news” situations, in which good communication skills are essential. These moments include communicating to the patient and/or family about a terminal diagnosis, the patient's prognosis, any treatment failures, deemphasizing efforts to cure and prolong life while focusing more on symptom management and palliation, advance care planning, and the patient's actual death.
Just as surgeons plan and prepare for major operations or investigators rehearse a presentation of research results, physicians and health care providers caring for patients with advanced illness must develop a practiced approach to sharing important information and planning interventions. In addition, families identify as important not only how well the physician was prepared to deliver bad news but also the setting in which it was delivered. For instance, 27% of families making critical decisions for patients in the intensive care unit (ICU) desired better and more private physical space to communicate with physicians, and 48% found having clergy present reassuring.
An organized and effective procedure for communicating bad news with seven steps goes by the acronym P-SPIKES: (1) prepare for the discussion, (2) set up a suitable environment, (3) begin the discussion by finding out what the patient and/or family understand, (4) determine how they will comprehend new information best and how much they want to know, (5) provide needed new knowledge accordingly, (6) allow for emotional responses; and (7) share plans for the next steps in care. Table 9-2 provides a summary of these steps along with suggested phrases and underlying rationales for each.

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Continuous Goal Assessment
Major barriers to ensuring quality palliative and end-of-life care include difficulty in providing an accurate prognosis and emotional resistance of patients and their families to accepting the implications of a poor prognosis. A practical solution to these barriers is to integrate palliative care with curative care regardless of prognosis. With this approach, palliative care no longer conveys the message of failure, having no more treatments, or “giving up hope.” Fundamental to integrating palliative care with curative therapy is to include continuous goal assessment as part of the routine patient reassessment that occurs at most patient-physician encounters.
Goals for care are numerous, ranging from cure of a specific disease, to relief of a symptom, to delaying the course of an incurable disease, to adapting to progressive disability without disrupting the family, to finding peace of mind or personal meaning, to dying in a manner that leaves loved ones with a positive “departure memory.” Discernment of goals for care can be approached through a seven-step protocol: (1) ensure that information is as complete as reasonably possible and understood by all relevant parties (see above); (2) explore what the patient and/or family are hoping for while identifying relevant and realistic goals; (3) share all the options with the patient and family; (4) respond with empathy as they adjust to declining expectations; (5) make a plan, emphasizing what can be done toward the realistic goals; (6) follow through with the plan; and (7) review and revise this plan periodically, considering at every encounter whether the goals of care should be reviewed with the patient and/or family. If a patient or family member has difficulty letting go of an unrealistic goal, suggest that, while hoping for the best, it is still prudent to have a plan for other outcomes

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Advance Care Planning
PRACTICES
Advance care planning is a process of planning for future medical care in case the patient becomes incapable of making medical decisions. Ideally, such planning would occur before a health care crisis or the terminal phase of an illness. Unfortunately, diverse barriers prevent this. While 80% of Americans endorse advance care planning and completing living wills, only 20% have actually done so. Most patients expect physicians to initiate advance care planning and will wait for physicians to broach the subject. Patients also wish to discuss advance care planning with their family. Yet patients with unrealistic expectations are significantly more likely to prefer aggressive treatments. Fewer than one-third of health care providers have completed advance care planning for themselves. Hence, a good first step is for health care providers to complete advance care planning for themselves. This makes providers aware of the critical choices in the process and the issues that are especially charged and allows them to tell their patients truthfully that they have done this themselves.
Steps in effective advance care planning center on (1) introducing the topic, (2) structuring a discussion, (3) reviewing plans that have been discussed by the patient and family, (4) documenting the plans, (5) updating them periodically, and (6) implementing the advance care directive (Table 9-3). The main barriers to advance care planning are problems in raising the topic and structuring a succinct discussion. Raising the topic can be done efficiently as a routine matter that is recommended for all patients, analogous to purchasing insurance or estate planning. It can be reassuring and effective if the physician has completed his or her own advance care directive.
Structuring a focused discussion is the central skill. Identify the health care proxy and recommend his or her involvement in the advance care planning process. Select a worksheet, preferably one that has been evaluated and demonstrated to produce reliable and valid expressions of patient preferences, and orient the patient and proxy to it. Such worksheets exist both for general and disease-specific situations. Discuss with the patient and proxy one scenario as an example to demonstrate how to think about the issues. It is often helpful to begin with a scenario in which the patient is likely to have settled preferences, such as being in a persistent vegetative state. Once the patient's preferences for interventions in this scenario are determined, suggest that the patient and proxy discuss and complete the worksheet for the others. If appropriate, suggest they involve family members in the discussion. On a return visit, go over the patient's preferences, checking and resolving any inconsistencies. After having the patient and proxy sign the document, place it in the medical chart and be sure that copies are provided to relevant family members and care sites. Since patients' preferences can change, these documents need to be reviewed periodically or after an illness episode or personal experience.

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TYPES OF DOCUMENTS
Advance care planning documents are of two broad types. The first includes living wills or instructional directives; these are advisory documents that describe the types of decisions that should direct care. Some are more specific, delineating different scenarios and interventions for the patient to choose from. Among these, some are for general use and others are designed for use by patients with a specific type of disease, such as cancer or HIV. Less specific directives can be general statements of not wanting life-sustaining interventions or forms that describe the values that should guide specific terminal care decisions. Health care proxy designation directives appoint an individual to make decisions. The choice is not either-or; a combined directive that both directs care and designates a proxy is often utilized, and the directive should clearly indicate whether the specified patient preferences or the proxy's choice should take precedence if they conflict.
A potentially misleading distinction relates to statutory as opposed to advisory documents. Statutory documents are drafted to fulfill relevant state laws. They tend to be written with the goal of protecting the clinician from legal action if they follow the patient's stated wishes. Advisory documents are drafted to reflect the patient's wishes. Both are legal, the first under state law, and the latter under common or constitutional law.

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LEGAL ASPECTS
As of 2003, 47 states and the District of Columbia had enacted living will legislation. Many states have their own statutory forms. Massachusetts, Michigan, and New York do not have living will laws. However, like all other states except Alaska, these states have enacted durable power of attorney for health care laws that permit patients to designate a proxy decision maker with authority to terminate life-sustaining treatments. Only in Alaska does the law prohibit proxies from terminating life-sustaining treatments.
The U.S. Supreme Court has ruled that patients have a constitutional right to decide about refusing and terminating medical interventions, including life-sustaining interventions, and that mentally incompetent patients can exercise this right by providing “clear and convincing evidence” of their preferences. Since advance care directives permit patients to provide such evidence, commentators agree that they are constitutionally protected. Most commentators believe that a state is required to honor any clear advance care directive. Many states explicitly honor out-of-state directives. If a patient is not using a statutory form, then a statutory form should be attached to the advance care directive being used.

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INTERVENTIONS
PHYSICAL SYMPTOMS AND THEIR MANAGEMENT
Great emphasis has been placed on addressing dying patients' pain. Some institutions have made it a fifth vital sign. While good end-of-life care requires good pain management, it also requires more. The frequency of symptoms varies by disease and other factors. The most common physical and psychological symptoms among all terminally ill patients include pain, fatigue, insomnia, anorexia, dyspnea, depression, anxiety, and nausea and vomiting. In the last days of life, terminal delirium is also common. Assessments of patients with advanced cancer have shown that patients experienced an average of 11.5 different physical and psychological symptoms (Table 9-4).

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And what is the Golden Path? you ask. It is the survival of humankind, nothing more nor less. We who have prescience, we who know the pitfalls in our human futures, this has always been our responsibility. Survival.
——Leto Atreides II the God Emporer of Dune: "The Journals of Leto", Hadi Benotto translation of the volumes discovered at Dar-es-Balat

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http://discworld.atuin.net/lpc/news.c?447182

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真的很长

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Pain
FREQUENCY
The frequency of pain among terminally ill patients varies widely. The proportion of
advanced cancer patients experiencing substantial pain is reported to range from 36 to
90%. In the SUPPORT study of hospitalized patients with diverse conditions and an
estimated survival of ≤6 months, 22% reported moderate to severe pain, and
caregivers of these patients reported that 50% had similar levels of pain during the last
few days of life.
Constipation Delirium
Cough
Swelling of arms or legs
Itching
Diarrhea
Dysphagia
Dizziness
Loss of libido
Fecal and urinary incontinence
Numbness/tingling in hands/feet
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ETIOLOGY
Nociceptive pain is the result of direct mechanical or chemical stimulation of
nociceptors and normal neural signaling to the brain. It tends to be localized, aching,
throbbing, and cramping. The classic example is bone metastases. Visceral pain is
caused by nociceptors in gastrointestinal, respiratory, and other organ systems. It is a
deep or colicky type of pain classically associated with pancreatitis, myocardial
infarction, or tumor invasion of viscera. Neuropathic pain arises from disordered,
ectopic nerve signals. It is burning or shocklike pain. Classic cases are post-stroke pain
and tumor invasion of the brachial plexus. Well-recognized pain syndromes are
associated with peripheral neuropathy after chemotherapy or surgery.
ASSESSMENT
Pain is a subjective experience. Depending upon the patient's circumstances,
perspective, and physiologic condition, the same insult can produce different levels of
reported pain and need for pain relief. Systematic assessment includes eliciting the
following: (1) periodicity—continuous, with or without exacerbations, or incident; (2)
location; (3) intensity; (4) modifying factors; (5) effects of treatments; (6) functional
impact; and (7) impact on patient. Several validated pain assessment measures may be
used, such as the Visual Analogue Scale, the Brief Pain Inventory, and the pain
component of the Memorial Symptom Assessment Scale. Frequent reassessments are
essential to assess the effects of interventions.
INTERVENTIONS
Interventions for pain must be tailored to each individual with the goal of preempting
chronic pain and relieving breakthrough pain. At the end of life, there is no reason to
doubt the patient's report of pain. Pain medications are the cornerstone of
management. If these are failing and nonpharmacologic interventions—including
radiotherapy, anesthetic or neurosurgical procedures, such as peripheral nerve blocks
or epidural morphine—are required, a pain consultation is appropriate.
P harmacologic interventions follow the World Health Organization
three-step approach involving nonopioid analgesics, mild opioids, and strong opioids,
with or without adjuvants (Chap. 11). Nonopioid analgesics, especially nonsteroidal
anti-inflammatory drugs, are the initial treatments for mild pain. They work primarily by
inhibiting peripheral prostaglandins, reducing inflammation, but may also have central
nervous system (CNS) effects. They have a ceiling effect. Ibuprofen, up to 1600 mg/d,
has a minimal risk of bleeding and renal impairment and is a good initial choice.
If nonopioid analgesics are insufficient, then opioids should be introduced. They work
by interacting with mu opioid receptors in the CNS to activate pain-inhibitory neurons;
most are receptor antagonists. The mixed agonist/antagonist opioids useful for postacute
pain should not be used for the chronic pain in end-of-life care. Weak opioids,
such as codeine, should be used initially. However, if the weak opioids are escalated
and also fail to relieve pain sufficiently, then strong opioids, such as morphine 5 to 10
mg every 4 h, should be used. Nonopioid analgesics should be combined with opioids
because they potentiate the effect of opioids.
For continuous pain, the opioids should be administered on a regular, around-the-clock
P.58
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basis consistent with their duration of analgesia. They should not be provided only
when the patient experiences pain; the goal is to prevent patients from experiencing
pain. Patients should also be provided rescue medication, such as liquid morphine, for
breakthrough pain and should be instructed to take one-half of the standing opioid
dose. Patients should be informed that using the rescue medication does not obviate
their taking the next standard dose of pain medication. If after 24 h the patient's pain
remains uncontrolled and recurs before the next dose, requiring the patient to utilize
the rescue medication, increase the daily opioid dose by the total dose of rescue
medications used by the patient, or by 50% for moderate pain and 100% for severe pain
of the standing opioid daily dose.
It is inappropriate to start with extended-release preparations. Once pain relief is
obtained, then switch to extended-release preparations. Even with a stable extendedrelease
preparation regimen, the patient may have incident pain, such as pain during
dressing changes. Short-acting preparations should be used to cover such predictable
episodes.
Because of differences in opioid receptors, cross-tolerance among opioids is
incomplete and patients may experience different side effects with different opioids.
Therefore, if a patient is not experiencing pain relief or is experiencing too many side
effects, change to another opioid preparation. When switching, begin with ≥50% of the
published equianalgesic dose of the new opioid. (Starting at 25% of the equianalgesic
dose is inadequate for terminally ill patients.) Opioids have no ceiling effect; therefore,
there is no maximum dose no matter how many milligrams the patient is receiving. The
appropriate dose is the dose needed to achieve pain relief. Addiction or excessive
respiratory depression is extremely unlikely in the terminally ill; fear of these side
effects should neither prevent escalating opioid medications when the patient is
experiencing insufficient pain relief nor justify using opioid antagonists, such as
naloxone.
Opioid side effects should be anticipated and treated preemptively. Nearly all patients
experience constipation that can be quite debilitating (see below). Failure to prevent
constipation often results in noncompliance with narcotic therapy. About a third of
patients experience nausea and vomiting, but tolerance develops, usually within a
week. Therefore, when beginning opioids, an antiemetic, such as metoclopramide or a
serotonin antagonist, should be prescribed prophylactically and stopped after 1 week.
Drowsiness, a common side effect of opioids, also abates within a week. During this
period, drowsiness can be treated with psychostimulants, such as dextroamphetamine
or methylphenidate. Anecdotal reports suggest that donepezil may also be helpful for
opiate-induced drowsiness. Metabolites of morphine and most opioids are cleared
renally; doses may need to be adjusted for renal failure.
Patients and families may withhold the prescribed opioids for fear of addiction or
dependence. Physicians and health care providers must reassure patients and families
that the patient will not become addicted or dependent upon the opioids if used as
prescribed for pain relief; this fear should not prevent the patient from taking the
medications around the clock.
Seriously ill patients with chronic pain relief rarely if ever become addicted. Suspicion
of addiction should not be a reason to withhold pain medications from terminally ill
patients. However, diversion of drugs for use by other family members or illicit sale may
occur. If this occurs, it should be managed in a way that does not inflict unnecessary
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pain on the dying patient. Contract writing with the patient and family can help. If that
fails, transfer to a safe facility may be necessary.
Tolerance is the need for increasing medication dosage for the same pain relief without
a change in disease. In the case of patients with advanced disease, the need for
increasing opioid dosage for pain relief is usually caused by disease progression rather
than tolerance. Physical dependence is indicated by symptoms from the abrupt
withdrawal of opioids and should not be confused with addiction.
Adjuvant analgesic medications are nonopioids that potentiate the analgesic effects of
opioids. In the management of neuropathic pain, tricyclic antidepressants, such as
desipramine, which has fewer side effects than other tricyclic antidepressants, can
begin to work in a few days at doses of 10 to 25 mg before bedtime. Similarly,
anticonvulsants, especially gabapentin (begun at 100 mg tid and titrated up by 100 mg
tid until relief, with usual doses between 300 mg and 1200 mg tid) or carbamazepine,
have shown effectiveness in relief of neuropathic pain. Glucocorticoids, preferably
dexamethasone provided once a day, can be useful in reducing inflammation that
causes pain while elevating mood, energy, and appetite. Other drugs, including
clonidine and baclofen, can be effective in pain relief. These drugs are adjuvants and
should all be used in conjunction with—not instead of—opioids. Methadone, carefully
dosed, has activity at the N-methyl D-aspartamate (NMDA) receptor and is useful for
complex pain syndromes and neuropathic pain.
Radiation therapy can treat bone pain from single metastatic lesions. Bone pain from
multiple metastases can be amenable to radiopharmaceuticals, such as strontium 89
and samarium 153. Pamidronate (90 mg every 4 weeks) and calcitonin (200 IU
intranasally once or twice a day) can also provide relief from bone pain.