2005-2006 > Academic research: refereed > Publication in refereed journalpublished_fina

Pang, SMC

Volicer, L

Leung, AWK

2005-2006 > Academic research: refereed > Publication in refereed journalVersion of RecordPublishe

PolyU Institutional Repository

 ????? ???????????????????????彭美慈　Ladislav V olicer　梁颖琴　　【??】　??　??????????????????????。　??　???????????????(BDSC)? 10 ????????? , ???????????????????????????。　??　BDSC ? 2 ??????????????:(1) ?????? , ????????????;(2) ????????? ,????????????。????????????????? ,????????? , ???????????。　??　BDSC ???????????? ,????????????????。???????????? ,????????????;???????????????????????;???????? , ????? ,????????????????????。　　【???】　??;　??? , ??;　????;　??????An empirical analysis of the decision-making of forgoing life-sustaining treatments for patients withadvanced dementia in the United States　P ANG Meiche S amantha * , Ladislav VOLICER , LEUNGWingkam Amanda . *School o f N ursing , The Hong Kong Poly technic University , Hong Kong ,Chian　　【Abstract】　Objective 　Considerable contro ver sy over the justifications fo r for going life-sustaining t reatment to patients w ith advanced dementia (AD) exists. Based on an ethnog raphicstudy , the decision-making practices fo r for going tube feeding and antibio tic treatment for AD patientsin the U. S is ex amined. 　Methods　P ro spective ca se studies w ere unde rtaken in a dementia specialca re unit(BDSC) over a pe riod o f six months. Da ta sources included clinical observ ation no tes fr om 10pa tient s , and inter view no tes fr om their family members and healthcare prov iders. Three strategieswere used to manage the data:event analysis , content analysis and cro ss-case analy sis. The AmericanCaucasian cultur e and hospice car e culture pro vided the contex t fo r ana ly sis. 　Results　Tw o pa tte rnsof decision-making were practiced in BDSC:(1) advance decision-making w ith respect paid to thepa tient's wishe s , and (2) advance decision-making fo cused on what is best fo r the patient. Differencesin justifica tions fo r forg oing tube feeding and forg oing antibiotic trea tment were discussed. 　Conclusions　Fo rgoing life-sustaining trea tment decision is difficult to make w ithin the clinical contex t.Underpinning these difficulties are the predominant v alues in curr ent medical practice that suppor t thebiolo gical de te rminants of life and medical techno lo gy for enhancing the quality o f life. In resolv ingthe se difficulties , a mo ral paradigm shift in tw o respects is required fo r framing the car e of patientsdying w ith AD. They are a shift fr om the medical pr otrac tion of life and a shift tow ards form s of caretha t enhance quality o f life within the natural-org anic framew ork of emo tional , rela tional , esthetic andspiritual w ell-being. In this study , a pa radigm shift of v alues underpinning the practice of fo rgo inglife-sustaining treatments fo r AD patients w as obser ved in three aspects. First , the emphasis onprogno stication based on biomedical ma rkers in predicting the leng th of surv iv al is shif ted to a focus onthe"diagno sis o f dying". This act facilitates the transition f rom connec ting the choice of t reatmentwith the goal of re so lving the eme rgent medical pr oblem to that o f the goal of comfor t care. Second ,the over riding concern in conventional medical practice with pr eser ving life is shif ting to an over ridingconcern o f"w ha t is best fo r the pa tient."Third , in the last day s o f life , the conventional appro ach of"tr ying to do eve rything for the patient"w as true in BDSC , but the appro ach had shifted fr om a　　????:??????????(Fu lbright HK Scholar Program 2002-3)????　　????:??????????(??? 、???);Geriat ric Research Educat ion &Clinical Center , BedfordVeteran Adminis t rat ion Medical Center (Ladislav Volicer)　　????:??? , Email:hs spang@inet . polyu. edu. hk300 ???????? 2005? 4?? 24?? 4?　Chin J Geriat r , April 2005 , Vol. 24 , No. 4technological to a relational one. Pro viding a peaceful and dignified environment in which the pa tientcould die in the last day s ar e the primary concern.　　【Key words】　Dementia;　Ethics ,medical;　Pa lliative ca re;　Cro ss-culture comparison　　??????????? ,?????????????? 。??????? (advanceddementia , AD)?????????????? ,????????(prognostic indicator)????????[ 1] 。AD????????????? ,??????????????? ,???????????????????[ 2-6] 。????????????? ,???????????? 、???????? 。?? AD?????????????????? ,????????????????????[ 7-11] 。?????? 1991 ???? “?????? (patient self-determinationact)” , ???????????????(advance directiv e)。???????? AD ????????? (tube feeding)[ 12] 。????????? ,?????????????????。???????????????????[ 13 , 14] 。? 1?? AD???????????????????? 。????????????????? AD??????:(1)?????????????????????????;(2)?????????[ 15] 。????????????????????????????????????????[ 6] 。?? ,?????????????? , AD????????????????????????????????[ 11] 。??? 2002 ? 12?? 2003 ? 5???? 10? AD???????????????????????????????? ,?????。?????? 、??10? AD???????????? ,??72 ～ 89? ,?? 79. 5 ?。????????????。? Reisberg ’ s (1988) ?????(functional assessment staging measure , FAS T),????? 7?[ 16] 。????????????? ,?????????????? ,????? ,???????。??????“???”?????? ,?????????????????? ,???????????[ 17] 。? 、?????????????? 6?????????。??????????? (ethnog raphiccase study),???????????????????????????? 。?????????????????? ,???????????????? (bedford dementia special care uni t ,BDSC)???? 。BDSC ??????????????? ,??????????[ 18 , 19] 。??????? (hospice care)????? ,???????“????”????? (? 1)。　　?????????????? ,??????????????? ,????????? 、?????????????。5????????。??????????????????????????? ,????????????? ,???? ,?????????? 。　　?????????? 3???:(1)???　　?: ??????????????? ,? 2 、3?　　? 1　AD ????????????????????301???????? 2005? 4?? 24?? 4?　Chin J Geriat r , April 2005 , Vol. 24 , No. 4? 1　BDSC ? AD????????? ?????? 1 (1)??????????????????;(2)?????????????? ,??????　　　????;(3)?????? ,?????????????　　　??。???? 2 (1)?????????????;(2)???? 1????????。?:??????????? ,????? 、?? 、??????;(2)?????????:??????????????? 、?????;(3)?????:?????? 、????????????????????????? 。?　　?BDSC ??????????? ????? ,?? 2 、3 。? 2????????????????? 。BDSC ? 10???? ,5???????????????:???????????? 。????????????????????。?????????????????????? ,????????????。?????????????????????????????????:??????????????。? 3??????????????????? ,?????????? 。????????????????????????????? 。????????????????????3 ～ 12???。?????????????????? ,???????????? 。?????????????????????? ,????????????? ,??????????? ,???????????? 。????? ,????????????????????? 。??????? BDSC ??????? (? 1),??????????????? ,?????????????????????????? 。　　? 2　?????? ,????????????　　? 3　????????? ,????????????302 ???????? 2005? 4?? 24?? 4?　Chin J Geriat r , April 2005 , Vol. 24 , No. 4　　5??????????? , 3????????? ,2?????????? 2 ,???????????。???? 5????? ,??????????????? 。??????????????????? 。???????:??????????????????????????。??????????? 3 ?:(1)???????????;(2)AD ??????????????????????? ,??????????;(3)?????????????????????[ 20] 。5????????????????????。?????????。?????????????????? ,???????????????。??????????????????? , 1 ～ 20 d?? 。?? ,??????????????? ,????????????? ,????????????? 。?????????????[ 21] ,????????? 。??????????? ,?????? ,????????? ,??????? 、??????????。??????????:???????????? ,?????。5?? ,? 2??????????????。???????? 89?? 84?。??????? ,????????;???????????????????? 。?3???????????????????? 。?????? 、????? ,????????????。???????????????????????? ,??????????????2 (? 1)。?　　???????? AD ???????? 。BDSC ????????? ,?????????????? ,???? 2???????? ,??????????????。? 20?? ,?????????? ,?????????? ,?????????? ,??????????????。70????? “?????” ,90????? “??????” ,?????????? ,?????????????;???????? ,???????????????。?? ,??????????????????。?? ,??????????? ,???:(1)??????????? ,???????????? ,?????????????? ,??????????? , ??????????? 。?????? ,???????????????? ,??????????????? 。???????????? ,?????????????????????????????;(2)????????????? ,????????? ,?????????????????。???????????? ,?????????????。BDSC ?????????? ,????????????????? ,???????????? ,?????? 。??????????????????? ,?????????????????????? ,??????。BDSC ??????????? ,?????????? 。????????????? AD ??????? ,???????????? , AD ????????????????? ,??????? ,????????????[ 22-26] 。BDSC ??????????????????????????????? ,???“????????” ;????????????????????? ,?????。???????? ,?????????????? AD????? ,??????????[ 15] 。????? ,???????????????????? 。?????????????? ,???????????。???????????? ,???????? ,???????? ,????????????????。??? , “?? 、??? 、???”?????????? ,????????????????????????。?? ,???????? ,?????????? ,??????????????????????????。?? ,???????????????? ,?????????? ,????????? 。??????? ,??????????? ,???????? ,???????????? ,???????[ 26] 。BDSC ????????????。?????????? ,???????????? ,??????????????? 。???????? ,?????????????303???????? 2005? 4?? 24?? 4?　Chin J Geriat r , April 2005 , Vol. 24 , No. 4?????????? ,?????? ,????? ,???????????????????? ,????????????? ,??????????????? ,??????????????????????? 。　　???　　本文内容国内很少涉及 ,但又是临床会面临的实际问题 ,实际操作往往涉及社会道德观念 、伦理 、法律 、法规等诸多问题 。过去强调生命绝对神圣 ,只要患者能存活一分钟 ,也要不惜一切代价抢救;而现代这种观念正在变化 ,更强调生命神圣 、质量和价值的统一 。因此 ,生命已处于低质量状态 ,积极治疗应改为临终关怀 。作者对美国一所护理中心 10例老年痴呆患者放弃维持生命治疗情况进行了调查分析 ,但我国仍未立法 ,所以刊出本文仅供参考 。?　?　?　?1 Ahronheim JC , Mor rison RS , Baskin SA , e t al.T reatment of the dying in the acute ho spital. Advanceddementia and metastatic cancer. A rch Intern Med ,1996 , 18:2094-2100.2 Reisberg B , Sclan SG , F ranssen E , et al. Dementiastaging in chr onic care populations. Alzheimer DisAssoc Diso rd , 1994 , 8(Suppl 1):S188-S205.3 Mo r rison RS , Siu AL . Surviv al in end-stag e dementiafo llowing acute illness. JAMA , 2000 , 284:47-52.4 Boller F , Verny M , Hugono t-Diener L , et al. Clinicalfeatures and assessment of sever e dementia. A review .Eur J Neurol , 2002 , 9:125-136.5 Aguer o-To rr es H , Qiu C , Winblad B , e t al.Dementing diso rders in the elde rly:evo lution of diseaseseverity ove r 7 yea rs. A lzheimer Dis Assoc Diso rd ,2002 , 16:221-227.6 The AM , Pasman R , Onwuteaka-Philipsen B , et al.Withholding the ar tificial administration of fluids andfo od from elde rly pa tients w ith dementia:ethnogr aphicstudy . BMJ , 2002 , 325:1326-1330.7 Lynn J , Teno J , Dresser R , et al. Dementia andadvance-car e planning: per spectives from threecountries on ethics and epidemiolog y. J Clinl Ethics ,1999 , 10:271-285.8 Hurley AC , Volicer L , Rempusheski VF , e t al.Reaching consensus: the pro ce ss of recommendingtreatment decisions fo r A lzheime r′s patients. Adv NursSci , 1995 , 18:33-43.9 Walker E , Dewa r BJ. How do we facilita te ca rers′inv olv ement in decision making  J Adv Nurs , 2001 ,34:329-337.10 Wilmo t S , Legg L , Barr att J. Ethical issues in thefeeding of patients suffering f rom dementia:a fo cusg r oup study of hospital staff r esponses to conflictingprinciples. Nurs Ethics , 2002 , 9:599-611.11 M ehr DR , Van de r Steen JT , Kruse R , et a l. Low errespirato ry infections in nursing home residents w ithdementia: a tale o f tw o countries. Ger ontologist ,2003 , 43 (Special I ssue I I):85-93.12 M itchell S L , Berkow itz RE , Law son FME , e t a l. Ac ross-na tional survey of tube feeding decisions incognitively impaired older per sons. JAGS , 2000 , 48:391-397.13 ?????????. ????????????????. ????????? , 2004.14 Hospital Autho rity H ong Kong. Guidelines on life-sustaining treatment in the terminally ill. H ong Kong ,Hospital Autho rity H ead O ffice , 2002. 25-26.15 Post S. The moral challenge o f A lzheimer disease:e thical issues f rom diagno sis to dying . 2nd ed.Baltimo re & London:The John Hopkins Univer sityPress , 2000. 96-109.16 Reisbe rg B. Functional assessment staging (FAS T).Psychopha rmacology Bulletin , 1988 , 24:653-659.17 Vo licer L , Berman SA , Cipolloni PB , et al. Per sistentv egeta tive state in A lzheimer′s disease. A rch Neurol ,1997 , 54:1382-1384.18 Vo licer L , Bloom-Charette L . Enhancing the quality oflife in advanced dementia . Philadelphia:Brunne r /M azel , 1999. 3-20.19 Vo licer L , Canto r M D , Der se AR , et al. Advance careplanning by pro xy fo r re sidents of long-te rm carefacilities w ho lack decision-making capacity. JAGS ,2002 , 50:761-767.20 M or ris J , Volicer L. Nutritional management ofindiv iduals w ith A lzheime r′ s disea se and otherpr og ressive dementias. Nutr Clin Care , 2001 , 4:148-155.21 Warden V , H ur ley AC , Vo licer L. Development andpsychomet ric evalua tion o f the pain assessment inadvanced dementia(PAINAD) sca le. J Am Med DirecAssoc , 2003 , 4:9-15.22 Post SG. The fea r o f fo rg etfulne ss: a g r assr oo tsappro ach to an e thics o f A lzheimer′s disea se. J ClinEthics , 1998 , 9:71-80.23 Hicks M H , Lam MS. Decision-making within thesocial course of dementia: accounts by Chineseame rican caregiver s. Cult Med Psychia try , 1999 , 23:415-452.24 Guo Z . Response to dementia-rela ted illness: ane thnog raphic study in a Chinese American community .I n:Zhan L . Asian Americans , vulne rable popula tions ,model Inte rventions , and clarify ing agendas. Jone sBar tlett Publisher s , 2003 , 253-267.25 Ikels C. Constructing and deconstructing the self:dementia in China. C ross Cultur Ge rontol , 2002 , 17:233-251.26 F inucane TE. Care of patients nearing death:anotherv iew . J Am Geri Soc , 2002 , 50:551-553.(????:2003-11-04)(????:???)304 ???????? 2005? 4?? 24?? 4?　Chin J Geriat r , April 2005 , Vol. 24 , No. 4

An empirical analysis of the decision-making of forgoing life-sustaining treatments for patients with advanced dementia in the United States

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Demets Éditeur, .

Daphy, Éliane

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An empirical analysis of the decision-making of forgoing life-sustaining treatments for patients with advanced dementia in the United States

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