Fear and loathing on the care path: treating pain and suffering.

P. Fine
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引用次数: 1

Abstract

Two recent court cases have gained widespread media attention and may create considerable worries among physicians. A precedent-setting verdict in a recent California case found, for the plaintiff, that insufficient pain management in a dying patient constituted abuse by a physician.1,2,3 In Utah, a physician who provided comfort care to terminally ill patients was accused of performing euthanasia, and he was tried on 5 counts of first-degree murder. He was convicted on several counts of negligent homicide and aggravated manslaughter.4 The conviction was over-turned after 6 months of imprisonment. This was due to the prosecutors' failure to disclose exculpatory evidence consisting of information revealed to the prosecution just before trial that care, as documented, reflected a good-faith effort to provide ethically justified treatments that may or may not have contributed to the timing of these patients' deaths. There is good cause for nervousness. These cases are a loud wake-up call to the medical profession. Fears of doing too little or too much should strongly motivate providers to attend carefully to the needs, goals, and values of their patients (or proxies). Clearly, the public is now demanding proficiency in palliative care, and it is a correct assertion that much can be done to mitigate suffering in the vast majority of cases without either killing patients or allowing intolerable distress. It is not surprising that most patients and their families know very little about palliative interventions and so act in seemingly irrational ways. Unfounded fears that opioid analgesics inevitably lead to addiction or hasten death are typical examples we must overcome through informed dialogue and counseling. However, we cannot enlighten them if we have not educated ourselves. Anxieties that physicians may have about being helplessly trapped by the public's current expectations into one type of error or another are certainly valid if they are insufficiently educated and trained in this area. With training and experience, it is rare that a physician would find herself or himself caught in one of the untenable extremes of what is actually an extensive and relatively safe field of palliative management strategies. However, like all other clinical areas that require expertise, what may be comfortable ground for knowledgeable and skilled practitioners may feel like a razor's edge to the ill prepared. What should scare us the most is not knowing and not acknowledging what we don't know. The obligation to know one's strengths, weaknesses, and limitations is fundamental to the integrity of our profession. Should the ethical imperatives to assess and relieve suffering be insufficient motivation, these legal cases should inspire each of us who cares for patients with chronic diseases, especially in their advanced states, to attend closely to quality-of-life issues. Individual physicians, medical societies and specialty organizations, schools of medicine, and postgraduate training programs need to acknowledge the lack of formal, disciplined grounding in palliative medicine. They then need to rapidly narrow the gap between society's appropriate expectations for adequate symptom management and our current capability to meet those expectations. These events are a call to action. Let's not be tempted to hunker down out of fear and defend the status quo but to embrace the opportunity to make a meaningful, positive difference in many peoples' lives.
治疗过程中的恐惧和厌恶:治疗疼痛和痛苦。
最近的两起法庭案件引起了媒体的广泛关注,并可能在医生中引起相当大的担忧。最近在加州的一个案件中,一项开创先例的判决发现,对原告来说,临终病人的疼痛管理不足构成了医生的虐待。在犹他州,一名为临终病人提供安慰护理的医生被指控实施安乐死,他被指控犯有5项一级谋杀罪。他被判犯有几项过失杀人罪和严重过失杀人罪监禁6个月后,判决被推翻。这是由于检察官未能披露无罪证据,这些证据包括在审判前向控方披露的信息,这些信息表明,根据记录,提供合乎道德的治疗是一种善意的努力,这种治疗可能导致这些病人的死亡时间,也可能没有。紧张是有充分理由的。这些案例给医学界敲响了警钟。对做得太少或太多的恐惧应该强烈地激励提供者仔细关注患者(或代理人)的需求、目标和价值观。显然,公众现在要求对姑息治疗的熟练程度,而且在绝大多数情况下,可以做很多事情来减轻痛苦,而不会杀死病人或允许无法忍受的痛苦,这是一个正确的断言。大多数患者及其家属对姑息干预知之甚少,因此采取了看似不合理的行动,这并不奇怪。对阿片类镇痛药不可避免地导致成瘾或加速死亡的毫无根据的恐惧是我们必须通过知情对话和咨询来克服的典型例子。然而,如果我们不教育自己,我们就不能启蒙他们。如果医生在这方面的教育和训练不足,他们可能会无助地被公众当前的期望困在这样或那样的错误中,这种焦虑当然是有效的。有了培训和经验,很少有医生会发现自己陷入一个站不住脚的极端,而实际上是一个广泛而相对安全的姑息治疗策略领域。然而,就像所有其他需要专业知识的临床领域一样,对于知识渊博和熟练的从业者来说,可能是舒适的环境,但对于准备不足的人来说,可能就像剃刀的边缘。最应该让我们害怕的是不知道和不承认我们不知道的东西。了解自己的长处、短处和局限性的义务是我们职业诚信的基础。如果评估和减轻痛苦的道德要求不足以激励我们,这些法律案件应该激励我们每一个照顾慢性病患者,特别是晚期患者的人,密切关注生活质量问题。个体医生、医学协会和专业组织、医学院和研究生培训项目需要认识到缓和医学缺乏正式的、有纪律的基础。然后,他们需要迅速缩小社会对适当症状管理的适当期望与我们目前满足这些期望的能力之间的差距。这些事件是行动的号召。让我们不要因为恐惧而畏缩不前,捍卫现状,而是要抓住机会,为许多人的生活带来有意义的、积极的改变。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
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