中國姑息治療解讀

中國姑息醫(yī)學(xué)的回憶和現(xiàn)狀

ReviewandStatusofPalliativeCareinChina李金祥Dr.JinxiangLi我國姑息醫(yī)學(xué)的進(jìn)展我國麻醉性鎮(zhèn)痛藥品的監(jiān)管法規(guī)我國姑息醫(yī)學(xué)的現(xiàn)狀我國姑息醫(yī)學(xué)效勞的三種模式我國姑息醫(yī)學(xué)實踐可獲得的藥品ThedevelopmentofPalliativecareinChinaTheruleonnarcoticanalgesicmanagementinChinaStatusofPalliativecareinChinaThethreemodelsofPalliativecareinChinaMedicationsofPalliativecareareavailableinChina我國姑息醫(yī)學(xué)的進(jìn)展〔1〕

ThedevelopmentofPalliativecareinChina我國姑息醫(yī)學(xué)效勞的常用臨床單位名稱：姑息關(guān)心科〔成都〕臨終關(guān)心病房〔天津，北京〕善終病房〔香港〕護(hù)理院〔上海〕安靜病房〔臺灣〕寧養(yǎng)院(汕頭)Thenameofpalliativeservicescommonly-usedinChina:Hospice〔Chengdu〕Wardsforterminalcare(Tianjin,Beijing)Wardsforgooddeath(HongKong)Nursinghomeforterminalillness(Shanghai)Hospitalforpeacefulandcomfortableincommunity(Shantou,Taiwan)姑息醫(yī)學(xué)在中國的進(jìn)展〔2〕1987年李偉在北京創(chuàng)辦“松堂臨終關(guān)心醫(yī)院”

1988年天津醫(yī)科大學(xué)成立“臨終關(guān)心爭論中心”1990年天津醫(yī)科大學(xué)建立臨終關(guān)心病房“SongtangHospice”wasestablishedbyLiWeiinBeijing,1987ThefirstHospiceResearchCentreinChinawasestablishedbyTianjinUniversityofMedicalSciences,1988WardsforterminalcarewassetupbyTianjinUniversityofMedicalSciences,19901990年衛(wèi)生部和WHO召開全國癌癥專題研討會，并把癌癥三階段止痛方案推向全國1991年、1994年和1999年我國三次修改嗎啡供給方法1990-2023年進(jìn)展屢次全國性癌痛和姑息治療學(xué)習(xí)班及臨終關(guān)心學(xué)習(xí)班TheNationalSymposiumonCancerwasco-heldbyMinistryofHealthandWHOin1990,inwhichthethree-stepanalgesicladderwasdisseminatednationwideThesupplyingmeasureofmorphineinChinawasamendedthreetimesrespectivelyin1991,1994and1999Thenation-widecampaignonthestudyofcancer-relatedpainandpalliativecarewascarriedoutformanytimesfrom1990to20231992年及1997年進(jìn)展了兩次全國癌痛現(xiàn)狀調(diào)查991年衛(wèi)生部公布第12號文件《關(guān)于開展癌癥病人三階梯治療工作的通知》，號召在全國開展“癌癥病人三階梯止痛治療工作”Thenationalsurveyonthestatusofcancer-relatedpainwascarriedouttwicein1992and1997respectivelyTheMinistryofHealthissuedthe12thdocumentTheNoticeontheimplementationofthree-stepanalgesicladderoncancerpatients,andcarriedoutthenation-wide“three-stepanalgesicladderoncancerpatientscampaign”in19911993年衛(wèi)生部出版《癌癥病人三階梯上痛指導(dǎo)原則》，并在全國推廣1994年衛(wèi)生部公布《關(guān)于公布癌癥病人申請麻醉藥品專用卡規(guī)定的通知》TheMinistryofHealthissuedTheguidingprinciplesonthethree-stepanalgesicladderoncancerpatientsin1993,anddisseminateditnation-wideTheMinistryofHealthissuedTheNoticeontheIssueoftheRegulationofAnalgesicsApplicationCardbyCancerPatientsin19941998年國家藥監(jiān)局〔SDA〕160號文件《關(guān)于癌癥病人使用嗎啡極量的通知》，指出：“癌癥病人使用嗎啡不受嗎啡極量限制”1999年華西醫(yī)科大學(xué)與美國AIMS舉辦第一界國際姑息醫(yī)學(xué)學(xué)術(shù)研討會，并建立“姑息關(guān)心病房”和“姑息醫(yī)學(xué)”雜志專欄The160thdocumentTheNoticeontheCeilingDosageofMorphineUsedbyCancerPatientsissuedbyStateDrugAdministration(SDA)in1998pointedoutthat“theamountofmorphineusedbycancerpatientsisnotrestrictedbytheceilingdosageofMorphine”WestChinaUniversityofMedicalSciencesandAIMSoftheU.S.co-organizedTheFirstSeminarofInternationalPalliativeCareofSichuanin1999,andstartedahospicebyDr.JinxiangLiandacolumnofpalliativecareinModernPreventiveMedicineJournal

1999年天津醫(yī)科大學(xué)與中國心理衛(wèi)生協(xié)會創(chuàng)辦《臨終關(guān)心雜志》1999年孫燕、顧慰萍主編“癌癥三階梯止痛指導(dǎo)原則”出版，2023年，2023年再版2023年,2023年四川大學(xué)與WHOOICPC在成都和昆明舉辦其次,三界國際姑息醫(yī)學(xué)學(xué)術(shù)研討會TianjinUniversityofMedicalSciencesandChinaAssociationofPsychologicalHealthstartedtheTerminalCareJournalin1999ThebookGuidingPrinciplesontheThree-stepAnalgesicTreatmentonCancerwaschief-editedbySunYanandGuWeipingandpublishedin1999,withasecondeditionin2023andathirdeditionin2023SichuanUniversityandWHOOICPCco-organizedtheSecondandThirdSeminarofInternationalPalliativeCareofSichuaninChengduandKunmingrespectivelyin2023and20232023年WHO授權(quán)在四川大學(xué)建立“WHO華西國際癌癥姑息治療合作中心”2023年李金祥譯著<<晚期癌癥病人口服嗎啡>>writtenbyDr.RobertTwycross2023年李金祥和Dr.RobertTwycross主編《姑息醫(yī)學(xué)》,由人民衛(wèi)生出版社出版SichuanUniversitywasauthorizedbyWHOin2023tosetup“WHO-HuaxiInternationalCollaboratingCentreforPalliativeCancerCare”JinxiangLitranslatedOralMorphineinadvancedcancerwithAdvancedCancerin2023,abookwrittenbyDr.RobertTwycrossPeople’sMedicalPublishingHousepublished《PalliativeMedicine》,whichwaseditedbyDr.JinxiangLiandDr.RobertTwycross.我國麻醉性鎮(zhèn)痛藥品監(jiān)管法規(guī)(1)

TheruleonnarcoticanalgesicmanagementinChina

麻醉藥品管制的宗旨：

TheNarcoticsManagementpurpose:

保證醫(yī)療需求,防止非法濫用。Ensuretheneedsofmedicaltreatment,prohibitillegalabuses.一、麻醉性鎮(zhèn)痛藥品監(jiān)管政策1950年11月，公布“治理麻醉藥品暫行條例”及實施細(xì)則規(guī)定由衛(wèi)生部指定特地藥廠生產(chǎn)指定中國醫(yī)藥公司負(fù)責(zé)供給其它任何機(jī)構(gòu)或個人均不得種植、制造、運(yùn)輸或銷售，違者依法論處1.PoliciesForNarcoticAnalgesicManagementInNovember1950,the“TemporaryPolicyonNarcoticmanagement”anditsadministrativedetailsareissued.ItisissuedthattheministryofHealthshouldappointspecialpharmaceuticalcompaniestomanufacturethedrugs.ChinaMedicalCorporationisappointedasthesupplier.Nootherorganizationsorindividualsareentitledtherighttoplant,manufacture,ormarket.Thosewhodisobeythelawwillsufferfromlegalconsequences.1963年5月，衛(wèi)生部會同公安部兩個部聯(lián)合發(fā)出加強(qiáng)麻醉藥品治理的通知，各項治理措施更為嚴(yán)格1978年，國務(wù)院公布了新的《麻醉藥品治理條例》及《實施細(xì)則》,對醫(yī)師使用資格及醫(yī)療單位購用麻醉藥品的限量均做了具體規(guī)定InMay1963,theMinistryofHealthandtheMinistryofPublicsecurityjointlyannouncedthedecisiononenhancingtheNarcoticControl.Eachitemofmanagementbecomesmorestrict.In1978,theStatecouncilissuedthenewNarcoticManagementPolicyandApplicationDetails,inwhichspecificrulesweremadeonmedicalworker’squalificationlicenseandthelimitamountformedicalorganizations’purchaseofnarcotics.1987年重新公布《麻醉藥品治理方法》是我國現(xiàn)行的麻醉藥品治理的政策依法加強(qiáng)治理，切實保證醫(yī)療、科研和教學(xué)上的正值需用，為人民安康效勞制止非法種植、生產(chǎn)、銷售和使用，以免發(fā)生流弊，轉(zhuǎn)化為毒品，危害人民安康TheNarcoticManagementPolicyre-issuedin1987isthepolicygoverningnarcoticmanagementinChinaatpresent.Enhancemanagementonthebasisoflaw,ensuremedicaltreatmentandtheappropriateapplicationofresearchandteaching,andservethewell-beingofpeople’shealth.Prohibittheillegalplanting,manufacturing,marketing,andapplicationsoastoavoidthecirculationandtransformationofdrugsandthedamagetopeople’shealth.1999年國藥監(jiān)局48號文件《關(guān)于癌痛治療使用麻醉藥品有關(guān)問題的通知》，“癌痛治療使用麻醉藥品控、緩釋制劑時，暫定一張?zhí)幏讲坏贸^15日常用量對芬太尼透皮貼劑，國家藥監(jiān)局1999年44號文件規(guī)定不得超過5貼，1999年48號文件將其用量擴(kuò)展為不得超過15日AccordingtotheNo.48regulationissuedbytheNationaldrugadministration—TheannouncementonsomequestionsrelatedtoUsingNARCOTICSInthetreatmentofcancer-inducedpain,whenapplynarcoticsinthetreatmentofcancer-inducedpain,theamountofdrugprescribedonetimeshouldnotexceedthecommondoseof15days.AccordingtotheNo.44RegulationissuedbytheNationaldrugadministrationin1999,thenumberofTDFentanylshouldnotexceed5patches.IntheNo.48Regulationissuedin1999,theamountofapplicationwasexpandedto15days.2023年關(guān)于印發(fā)《癌癥患者申辦麻醉藥品專用卡的規(guī)定》，該文件對1994年的文件做了較大修改In2023,theissueof《RegulationofCancerPatientsApplyingfortheSpecificCardforNarcoticAnalgesicsUse》madesignificantchangestotheregulationissuedin1994二、醫(yī)院麻醉性鎮(zhèn)痛藥品使用法規(guī):目的：確保麻醉藥品的醫(yī)療應(yīng)用和科研需要,嚴(yán)防流入非法渠道

2.TheregulationforusingNarcoticanalgesicsinhospital.Objectives:ensurethemedicalapplicationandresearchrequirementsoftheanalgesics,prohibitthecirculationintotheillegalchannels.

1．短期鎮(zhèn)痛、止咳的門診患者：注射劑不超過常用量，只限患者就診時使用，嚴(yán)禁交患者自用片劑、酊劑、糖漿劑不得超過3日常用量，連續(xù)應(yīng)用不得超過7天住院病人使用麻醉藥品醫(yī)囑、病歷、手術(shù)記錄應(yīng)與處方相符。麻醉鎮(zhèn)痛藥品連續(xù)使用不得超過七天，注射劑不得超過常用量1.Shot-termpainrelief,anti-coughingtoout-patients:Theinjectiondoseshouldnotexceedthecommondose.Theapplicationisonlyrestrictedtowhenthepatientsseekformedicalcare.Theapplicationshouldnotbeleftatthehandofthepatients.Pills,tincture,syrupusshouldnotexceedthecommondoseof3days.Theapplicationshouldnotexceed7daysinarow.Order,historyandoperationrecordsofanalgesicsforin-patientsshouldbeconsistentwiththeprescription.Narcoticanalgesicsshouldnotbeusedformorethansevendays,andinjectionsshouldnotexceedcommondose.2.嚴(yán)峻慢性苦痛病人:用非甾體類鎮(zhèn)痛藥和弱阿片類藥物不能止痛的,可使用強(qiáng)阿片類藥物，如嗎啡緩〔控〕釋制劑，TD芬太尼和羥考酮緩釋劑止痛目前暫定二級以上醫(yī)療機(jī)構(gòu)具有麻醉藥品處方權(quán)的執(zhí)業(yè)醫(yī)師,方可開具強(qiáng)阿片類制劑，用于慢性癌痛的患者2.PatientswithChronicSeverePain:IfthepainisnotrelievedbyusingNSAIDswithweakopioidsOpiates,strongopioidsshouldbeusedTDFentanylAtpresent,physicianswithprescriptionlicenseinmedicalorganizationsabovesecondlevelarepermittedtoprescribestrongopioidinthetreatmentofpatientswithchroniccancerpain.3.醫(yī)師處方麻醉性止痛劑的職責(zé)：僅由一位被授權(quán)的執(zhí)業(yè)醫(yī)師負(fù)責(zé)開處方使用強(qiáng)阿片類藥物之前，患者和醫(yī)師必需對治療方案和預(yù)期效果達(dá)成共識，患者必需簽署知情同意書3.Theresponsibilityofnarcoticanalgesicsprescriptedbyphysician:Onlyoneauthorizedphysicianshouldberesponsibleforprescription.BeforestrongOpioidsused,acommonunderstandingshouldbeobtainedbyboththepatientandphysician,andaninformedconsentneedtobesignedbypatient.依據(jù)三階梯鎮(zhèn)痛療法，鎮(zhèn)痛藥物應(yīng)按時賜予病人應(yīng)至少每周就診一次，以便調(diào)整處方經(jīng)治醫(yī)師要定期隨訪病人，開頭時應(yīng)較頻繁〔如每周一次〕Analgesicsshouldbeadministeredbytheclockandbytheladder.Thepatientneedtoseethedoctoratleastonceaweeksoastoadjustthedosage.Thephysicianshouldfollowuphispatients,morefrequentlyatthebeginning(e.gonceaweek).4.癌癥患者使用麻醉性止痛劑的原則：用藥必需辦理麻醉藥物專用卡(麻卡),辦卡需提交縣級醫(yī)院以上〔包括縣級醫(yī)院〕,開具的診斷證明，戶口冊，身份證原件及復(fù)印件，患者居住地居民委員會或村民委員會的證明信辦卡需提交患者有關(guān)癌癥診治的病歷，相關(guān)檢查治療的復(fù)印件，并加蓋原診斷機(jī)構(gòu)印章4.ThePrincipleofNarcoticanalgesicuse:TheSpecificCardforNarcoticAnalgesicsUseshouldbeappliedforbeforesuchanalgesicsareused.Diagnosticevidenceissuedbycounty-levelhospital(includingcounty-hospital),residencebooklet,originalIDcardandaphotocopy,andatestimonialprovidedbylocalresidents’committeeareneededfortheapplication.Medicalrecordrelatedtocancerdiagnosis,photocopiesofrelatedmedicalexaminationswithofficialsealofthehospitalarealsoneeded.麻卡期限為二個月，使用期滿二個月需連續(xù)使用的，憑單位證明信和戶口冊，重新辦理換卡手續(xù)辦卡必需要見到病人連續(xù)使用麻醉藥品6個月后，再次更換新卡時，須供給醫(yī)療機(jī)構(gòu)的復(fù)診證明Thecardfortheanalgesicsonlyvalidfor2months.Ifthecardneedtobeusedcontinuously,renewalcouldbeappliedwithatestimonialprovidedbythepatient’sworkunitandresidencebooklet.Thepatientshouldbepresentedontheoccasionofcardapplication.AftercontinuouslyNarcoticAnalgesicsusefor6months.Testimonialforre-diagnosisofferedbythehospitalisneededonrenewal.對于使用卡的病人，醫(yī)生必需每月面診病人，建立大病歷，記錄病人的苦痛狀況病人去世后交回麻卡并無償交回剩余的麻醉藥品Thephysicianandpatientwithacardshouldmeeteverymonth,andmedicalrecordsshouldbeestablishedtorecordpainstatusofthepatient.Thecardshouldbehandinandremainednarcoticanalgesicsshouldbereturnedwithoutcompensationafterthepatient’sdeath.5.麻醉性鎮(zhèn)痛藥品使用劑量：使用無極限劑量注射劑一次不超過三日用量控〔緩〕釋制劑處方不超過十五日劑量其他劑型的處方一次不超過七日用量麻醉藥品注射劑一般不供給5.DosageofnarcoticanalgesicapplicationNoseilingdoseshouldbelimited.Oneinjectiveagentshouldnotexceedthedosesforthreedays.Prescriptionofcontrolled-releasedoseshouldnotexceed15days.Prescriptionofotherdoseshouldnotexceed7days.Theinjectablesolutionofnarcoticanalgesicsisnotusuallyprovided.住院和門診患者在開具控緩釋制劑時，可同時使用即釋麻醉藥品，以緩解活動時的劇痛晚癌病人不提倡使用度冷丁鹽酸二氫埃托啡片只限二級以上醫(yī)療機(jī)構(gòu)的住院病人使用Normal-releaseandcontrol-releasenarcoticanalgesicsmayconcurrentlybeusedtorelieveseverepaininmovementforin-andout-patients.Pethidineisnotrecommendedforpainreliefinadvancedcancer.Dihydroetorphinehydrochlorideshouldonlybeusedinhospitalsonandabove2ndlevel.三、醫(yī)師開具處方的規(guī)定：具有執(zhí)業(yè)醫(yī)師資格，經(jīng)市級以上衛(wèi)生主管部門考核合格,并能正確使用麻醉藥品，才能授予麻醉藥品處方權(quán)開具麻醉藥品應(yīng)使用專用淡紅色紙質(zhì)處方，依據(jù)《處方治理方法》的規(guī)定開具處方。處方上寫明臨床診斷3.Regulationofphysician’sprescriptionNarcoticanalgesicprescribingauthorityshouldonlybeauthorisedtocertifiedphysicianswhohavepassedexaminationsheldbymedicaladministrativedepartmentabovecitylevelandareabletousenarcoticanalgesiccorrectly.Narcoticanalgesicsshouldbeprescribedwithpaleredprescribingpaperandaccordingtotherulesin<PrescriptionAdministrationRegulation>.Clinicaldiagnosisofcancershouldbewrittenclearlyontheprescriptionpaper.四.麻醉藥品治理方面的規(guī)定RegulationsonNarcoticanalgesicmanagement五.專治理:專人負(fù)責(zé),專柜架鎖專用賬冊,專用處方專冊登記

FiveSpecificManagement:specificpersoninchargespecificlockedcabinetspecificcounterspecificprescriptionspecificregistration

五.麻醉性鎮(zhèn)痛劑—嗎啡醫(yī)療消耗量1983年7kg(0.006mg/人)2023年253kg(0.195mg/人)20世紀(jì)90年月后半期比80年月增長18.52倍21世紀(jì)第1、2年比20世紀(jì)80年月增長33.63倍AnalgesicMedicationMorphineConsumptionformedicine7kg(0.006mg/perhead)in1983253kg(0.195mg/perhead)in2023Thesecondhalfof90sin20thcenturyincreased18.52foldscomparedtothe80sThefirsttwoyearsofthe21stcenturyincreased33.63foldscomparedtothe80sof20thcentury

興旺與進(jìn)展中國家2023年的嗎啡醫(yī)療消耗量

TheContrastontheAmountofMedicalMorphineConsumptionbetweendevelopedcountriesandthedevelopingcountriesin2023

國家n

人口population醫(yī)療消耗量Medicalconsumption百萬million%kgMg/人%A271049.726.72541224.2192.8

B672886.773.319610.687.2C—1295.332.92530.1950.9A：興旺國家(developedcountry)B：進(jìn)展中國家(developingcountry)C：中國(China)

六.麻醉藥品合法使用中的問題最大障礙是“成癮恐驚癥”病人藥品用量缺乏麻醉藥品品種使用不合理三階梯癌痛治療必需進(jìn)一步推廣醫(yī)生和患者對苦痛治療的重視程度需要提高6.LegaluseofnarcoticanalgesicsThestrongestobstacleis“opiophobia”InsufficientdoseofthenarcoticanalgesicsUnappropriateuseofthenarcoticanalgesics3-stepanalgesicladdershouldbegeneralizedDoctors’andpatients’emphasisonpainreliefshouldbestrengthened.我國姑息醫(yī)學(xué)的效勞現(xiàn)狀

StatusofPalliativecareserviceinChina多種臨床效勞模式：專科住院效勞單位〔hospice〕—姑息關(guān)心科，臨終關(guān)心醫(yī)院，護(hù)理院,苦痛科〔麻醉科大夫〕兼代癌痛掌握單位—腫瘤科，老年科和內(nèi)科醫(yī)師兼代從事癌痛掌握社區(qū)關(guān)心效勞單位—寧養(yǎng)院〔上門巡診與隨訪相結(jié)合〕

MultipleClinicalServiceModels:Hospice–DepartmentofPalliativeCare,TerminalCare,nursingdepartment,pain-reliefDepartment(physicianofanesthesia)DepartmentConcurrentInChargeofcancerpainrelief—CarcinomaDepartment,SenilityDepartment,andphysiciansconcurrentlytakingchangeofcancerpainrelief.Careunitincommunity—NingYangYuan(thecombinationofhomevisitandtelephonefollow-up.

住院效勞單位(1)

AdmissionServiceUnit(1)姑息關(guān)心科:掌握苦痛和緩解病癥,改善生存質(zhì)量；末期關(guān)心照護(hù),為末期病人供給善終效勞臨終關(guān)心醫(yī)院:針對慢性心腎肺腦患者,高齡老人供給照護(hù)起居,日常生活,心理輔導(dǎo)和末期關(guān)心效勞PalliativeCareDepartment:paincontrolandsymptomrelief,improvethequalityoflife,terminalcare,providegood-deathservicetopatientswithterminaldisease.HospitalforTerminalCare:providepsychologicalcounseling,andterminalcareserviceforpatientswithchroniccardial,pneumonic,renal,andheartdiseaseandoldpeople.住院效勞單位(2)

AdmissionServiceunit(2)

兼代癌痛掌握單位:腫瘤科、老年科和內(nèi)科醫(yī)師在抗癌治療同時,兼代作癌痛治療,能嫻熟應(yīng)用“WHO三級鎮(zhèn)痛階梯”,但不少醫(yī)生擔(dān)憂成癮和呼吸抑制,仍停留在肌注杜冷丁鎮(zhèn)痛Unitsconcurrentlyinchargeofcancerpainrelief:Oncologicdepartment,thegeriatricdepartment,andphysicians,whilemakinganti-cancertreatment,alsomadecancerpainreliefeffort.Theycanskillfullyusethe“WHO3-stepanalgesicladderforcancerpain.However,manyphysiciansworryabouttheaddictionandrespiratorydepression,sotheystillstayatthestageofmuscle-injectionofpathedine.

住院姑息關(guān)心效勞單位

TheUnitsofPalliativeCareforAdmission川大華西第四醫(yī)院姑息關(guān)心效勞

ClinicalServiceofpalliativecareinWestChinaFourthHospitalofSC病房有22張床,一個診斷室,4名醫(yī)生13名護(hù)士,其中專職從事姑息關(guān)心效勞的3名醫(yī)生和1名護(hù)士在英國牛津受過專業(yè)培訓(xùn)收治晚期癌癥和無生物學(xué)前景的末期疾病患者醫(yī)生每天查房兩次(上午和下午),1名醫(yī)生和1名護(hù)士全天24小時值班Thereare4physiciansand13nursesinthewardswith22beds.Toprovidetheserviceforterminalpatientsinadvancedcancerandnoprospectofbiology.Doctorsarewardroundeveryday,adoctorandanurseareondutyfor24hoursonrotation.多數(shù)病人來自門診,局部病人從其他醫(yī)院轉(zhuǎn)來姑息治療學(xué)問主要來源于Dr.Robert的幾本著作嚴(yán)格將“WHO三級鎮(zhèn)痛階梯”用于臨床住院病人應(yīng)用無極限劑量阿片類藥物,門診病人一張?zhí)幏降陌⑵悜?yīng)限制在3-7天內(nèi)的藥物Mostofpatientscomefromout-patient,somepatientsaretransferredfromotherdepartments.KnowledgeofpalliativecaremainlycomesfromDr.RobertTwycross’sseveralbook.UsetheWHOthree-stepanalgesicladder.Useofopioidsisnotlimitedinthewards,butprescriptionofopioidsforoutpatientislimitedinthreedays.

門診病人憑當(dāng)?shù)厮幤繁O(jiān)管的“麻卡”購置阿片類必要時作姑息性放化療以掌握病癥不再做拖延死亡的治療和終末期病人的復(fù)蘇治療Patientsatout-patienthavetohavespecialcertificatefromLocalHealthBureauforprescriptionofopioids.Developpalliativeradiotherapyandchemotherapyforsymptomcontrol.Nolongeradvisetreatmenttopostpone-death,notcardiopulmonaryresuscitationtoterminalpatients.對病癥供給理療,但無工療病房無義工,神職人員沒有日托和淋巴水腫的效勞,護(hù)理主要是家屬和/或雇人照護(hù)應(yīng)用中西醫(yī)結(jié)合掌握病癥和苦痛宣傳姑息關(guān)心的概念,培訓(xùn)和教育相關(guān)的醫(yī)護(hù)人員Usephysiotherapy,noserviceofoccupationaltherapy.Nosocialworker,chaplainandvolunteerinhospital.Nodaycentreandlymphoedemaservices,carersaremainlyrelatives.Usecombinationwestmedicineandtraditionalmedicineforsymptomcontrol,suchasacupunctureandherbsforpainrelief.Propagandatheideaofpalliativecare,anddevelopthetrainingandeducationforhealthprofessionals.

社區(qū)姑息關(guān)心效勞單位:寧養(yǎng)院

PalliativeCareUnitsinCommunities:

NingYangYuan

寧養(yǎng)院:“寧養(yǎng)”含安靜，養(yǎng)護(hù)的意思，實際上是一種姑息關(guān)心機(jī)構(gòu)于2023年在汕頭成立全國首家寧養(yǎng)院,現(xiàn)共有20家NingYangYuan:“NingYang”connotesquietnessandrecuperation.ItisinfactatypeofPalliativeCareUnit.ThefirstNingYangYuanofthecountrywassetupin2023inShantou.Nowtherearealltogether20suchunitsinChina.

20家寧養(yǎng)院分布圖TheDistributionofThe20NingYangYuan

汕頭大學(xué)醫(yī)學(xué)院第一附屬醫(yī)院(總院)

·北京天壇醫(yī)院(Beijing)

·福建省立醫(yī)院(Fujian)

·深圳市人民醫(yī)院(shenzhen)

·天津市第一中心醫(yī)院(tianjin)

·廣東醫(yī)學(xué)院附屬醫(yī)院(guangdong)

·中國醫(yī)科大學(xué)其次附屬醫(yī)院(Beijing)

·大連醫(yī)科大學(xué)第一附屬醫(yī)院(dalian)

·上海其次醫(yī)科大學(xué)附屬新華醫(yī)院(shanghai)

·哈爾濱醫(yī)科大學(xué)附屬腫瘤醫(yī)院(Haerbin)

·武漢大學(xué)中南醫(yī)院(wuhan)北京腫瘤醫(yī)院(Beijing)·廣東粵北人民醫(yī)院(Guangdong)

·廣東潮州市中心醫(yī)院(Guangdong)

·蘭州醫(yī)學(xué)院第一附屬醫(yī)院(Lanzhou)

·江西醫(yī)學(xué)院第一附院(jiangxi)·新疆醫(yī)科大學(xué)附屬腫瘤醫(yī)院(xijiang)

·廣西醫(yī)科大學(xué)第一附屬醫(yī)院(guangxi)

·暨南大學(xué)醫(yī)學(xué)院第一附屬醫(yī)院(guangzhou)

·重慶醫(yī)科大學(xué)第一附屬醫(yī)院(chongqing)寧養(yǎng)院的分布寧養(yǎng)院效勞的模式

TheservicemodelofNingYangYuan對晚期貧困癌癥病人上門免費(fèi)效勞“以人為本，全人效勞”居家效勞，詢問效勞，門診效勞鎮(zhèn)痛治療，心理輔導(dǎo)，寧養(yǎng)學(xué)問宣教Charge-freeserviceathomeforthosepoorpatientsinadvancedcancer“Peoplebeingthemostimportant,whole-personservice”ServiceProvidedathome,counselingservice,andout-patientservice.Painrelief,Psychological,andtheinformingofNingYangknowledge.綜合性醫(yī)院末期疾病患者的治療現(xiàn)狀

Thestatusofpatient’sManagementforterminalillnessinthegeneralhospitals

＞80%末期疾病患者未得到苦痛緩解和病癥掌握很多病人及家屬要求安樂死,少數(shù)甚至由于無法忍受軀體和心理上的苦痛而自殺>80%ofthecancerpatientsatterminalstagehaven’tgotsymptomcontrolandpainmanagementmanypatientandrelativesrequesteuthanasia,afewevencommitsuicidetoavoidtoexcruciatingcancerpainalongwithphysicalandemotionaldistress.堅持放化療直到死亡對末期患者堅持“不惜一切代價”救治生命的理念insistonradiotherapyandchemotherapyuntilpatientdeath.insistontheprincipleoflife-saving“atallcosts”toterminalpatients.

對瀕死患者進(jìn)展延長死亡的維持治療,如輸液,輸血,輸養(yǎng)分等直到死亡盡管心跳呼吸已經(jīng)停頓,仍舊進(jìn)展心肺復(fù)蘇,人工通氣,心內(nèi)注射,胸壁按壓Stillmaintaintreatmentsforprolonging-deathatterminalphase,suchasinfusion,bloodtransfusion,nutrition,antibioticsinfusionandoxygen,untilpatientdeath.Continuecardiopulmonaryresuscitation,persistentlyartificialventilationusingamask,useintra-cardiacinjectionafterthecardiopulmonaryStopped,compressionofthechestwalltomaintaincirculation.

受傳統(tǒng)觀念影響,內(nèi)科醫(yī)生擔(dān)憂阿片成癮,呼吸抑制,缺乏新的科學(xué)學(xué)問,他們決不用嗎啡緩解苦痛,但堅持使用哌替定(杜冷丁)鎮(zhèn)痛衛(wèi)生執(zhí)業(yè)者與病人及家屬缺乏恰當(dāng)?shù)臏贤?極少告之診斷,決不談?wù)擃A(yù)后和死亡Physicianworryaboutopioidaddiction,respiratorydepressionandlacknewscientificknowledge,theyneverusemorphinetoreliefpainforthedyingpatient.But,theyalwaysusepethidineforpainrelief.Lackofcommunicationsbetweenhealthprofessionals,patientsandrelatives,nevertellpatientsabouttheirdiagnosisandprognosis.可供晚期惡性疾患治療應(yīng)用的藥物

medicationsformalignentillnessesareavailableinChina阿片類藥物opioids非阿片類藥物non-opioids幫助類藥物adjuvantanalgesics其他類藥物others阿片類藥物

opioids強(qiáng)阿片類藥物strongopioids嗎啡緩釋片:美菲康

MorphineHydrochlorideControlled-releaseTablets嗎啡控釋片:美施康定

MorphineSulfateModified-releaseTablets嗎啡即釋片morphinenormal-release嗎啡針劑morphineforinjectablesolution

強(qiáng)阿片類藥物strongopioids美沙酮methadone:戒毒芬太尼透皮劑TDfentanyl

羥考酮oxycodone布托啡諾鼻噴劑butorphanolnasalspray鹽酸二氫埃托啡dihydroetorphine丁丙喏啡buprenorphine弱阿片類藥物weakopioids曲馬多tramadol可待因codeine哌替啶pethidine雙氫可待因dihydrocodeine復(fù)方制劑：opioidcompoundpreparations氨酚羥可酮Mallinckrodt:Oxycodone5mg

Acetaminophen325mg阿片類拮抗劑：opioidantagonist納洛酮naloxone非阿片類藥物non-opioids阿司匹林Aspirin對乙酰氨基酚Acetaminophen非甾類抗炎藥物NSAIDs非甾體類抗炎藥(NSAIDs)：雙氯芬酸鈉diclofenac

氟布洛芬flubiprofen羅非昔布rofecoxib

塞萊昔布celecoxib美洛昔康

meloxican

氯諾昔康lomaxicam布洛芬ibuprofen

萘普生naproxen吲哚美辛indometacin幫助類藥物adjuvants皮質(zhì)類固醇激素steroids抗癲癇類anti-epileptics精神抑制性藥物neuroleptics:TCASSRI

苯并二氮卓類benzodiazepines止吐藥anti-emetics緩瀉劑laxatives其他藥物

others皮質(zhì)類固醇激素Steroids：地塞米松dexamethason強(qiáng)的松prednisone強(qiáng)的松龍prednisolone抗癲癇類Anti-epileptics

蓋巴丁gabapentin苯妥因phenytoin卡馬西平carba