非脑死亡患者放弃治疗的原因分析及临床策略

通过对本院2007年～2008年399例放弃治疗后死亡的病历分析,探析放弃治疗的原因,探讨临床对策.病情恶化是放弃治疗的主要原因.放弃治疗涉及医学、哲学、法律等多方面问题.医生应该尽告知义务,尊重患者的生命权、健康权,知情权、选择权和决定权.放弃治疗后,工作的重点应转向安抚和临终关怀,同时规范"放弃治疗"的医学文书.     

放弃治疗后,以护理为主导的医学服务和人文关怀

剖析放弃治疗后死亡病案508例,分析放弃治疗的原因、疾病和形式,放弃治疗后护理工作存在的问题.提出在放弃治疗后,临床护理决策:对于护理工作发生的变化,应该提高认识,培养护理人员人文素质和法律意识,应该加强护理管理和规范,放弃治疗后,护理应该承担医学服务和人文关怀的主导作用.     

非脑死亡患者放弃治疗的原因分析及临床策略

通过对本院2007年～2008年399例放弃治疗后死亡的病历分析,探析放弃治疗的原因,探讨临床对策。病情恶化是放弃治疗的主要原因。放弃治疗涉及医学、哲学、法律等多方面问题。医生应该尽告知义务,尊重患者的生命权、健康权,知情权、选择权和决定权。放弃治疗后,工作的重点应转向安抚和临终关怀,同时规范"放弃治疗"的医学文书。     

放弃治疗的法律和伦理学思考

调查放弃治疗后死亡病案629例,主要病因为恶性肿瘤和脑血管病.目前在临床工作中,对疾病晚期和临终期的患者,放弃治疗已成为家属和患者本人重要的选择之一.医患双方应该尊重医学科学,理性对待放弃治疗,履行双方应尽的义务,维护双方合法权力,维护法律的尊严.医院应该加强管理,正确处理放弃治疗的相关问题,更好地服务于患者和社会.     

放弃治疗后，以护理为主导的医学服务和人文关怀

剖析放弃治疗后死亡病案508例,分析放弃治疗的原因、疾病和形式,放弃治疗后护理工作存在的问题。提出在放弃治疗后,临床护理决策：对于护理工作发生的变化,应该提高认识,培养护理人员人文素质和法律意识,应该加强护理管理和规范,放弃治疗后,护理应该承担医学服务和人文关怀的主导作用。     

有关放弃治疗的临床决策

在临床工作中,患者因某些原因不能得到有效或常规的治疗,而最终选择停止继续治疗、即放弃治疗,及时、合理、正确地处理放弃治疗对患者、医务人员、家庭、社会等是极其重要的.对临床上常见的放弃治疗原因进行了全面分析,包括患方、医生、功利、无奈、道德等方面的原因,并提出了解决放弃治疗的临床决策,该研究为临床治疗过程中提供了重要的理论参考.     

农村与城镇终末期肾病患者临床状况比较分析

时比分析农村与城镇终末期肾病患者的临床状况,旨在了解新农合政策带给农村终末期肾病患者的益处及今后还需完善和努力之处.对广西壮族自治区人民医院血液净化治疗中心2007年新增的238例终末期肾病患者按农村与城镇进行分组对比分析.96例农村患者,88例选择血液透析,8例放弃治疗;142例城镇患者,23例选择腹膜透析,108例血液透析,11例放弃.无论是城镇还是农村患者慢性肾炎为主要的原发病、都存在透析过晚、并发症发生率高、急诊透析率高的现象.与城镇组相比,农村组患者平均年龄、肾痛知晓率、残余肾功能、血红蛋白、二氧化碳结合力、尿素清除指数低于城镇组(P<0.05);梗阻性肾病发病率、并发症发生率、急诊透析率、死亡率、失访率高于城镇组(P<0.05).新农合的实施使农村终末期肾病患者获得了治疗的机会,针对农村患者肾病知晓率低、临床状况差的特点,需加强农村慢性肾病的防治工作.     

产前筛查的几点思考

在临床工作中,患者因某些原因不能得到有效或常规的治疗,而最终选择停止继续治疗、即放弃治疗,及时、合理、正确地处理放弃治疗对患者、医务人员、家庭、社会等是极其重要的。对临床上常见的放弃治疗原因进行了全面分析,包括患方、医生、功利、无奈、道德等方面的原因,并提出了解决放弃治疗的临床决策,该研究为临床治疗过程中提供了重要的理论参考。     

ICU谵妄患者病因分析以及处理

分析急诊ICU患者出现谵妄症状的原因以及处理对策.分析总结我院急诊ICU 3年间所有患者的资料,发现20.2％的患者出现谵妄症状,原因为:(1)疾病相关；(2)药物相关；(3)监护环境等多种因素作用结果.经过调整治疗方案、加强心理护理后,需要镇静药物的仅为谵妄患者的19.7％.因此寻找谵妄原因很重要,治疗重点在于去除谵妄原因以及相关促发因素.     

3例误诊为急性冠脉综合征实施介入诊治死亡病例的启示

探讨3例被误诊为急性冠脉综合征(ACS)而急诊实施介入诊治死亡病例的临床特点及误诊原因,提高对ACS的诊断意识.收集我院比较典型的3例误诊死亡病例进行回顾性分析.3例死亡病例中1例为肺栓塞、1例为主动脉夹层动脉瘤(AD)、1例为流行性出血热,3例均实施了冠状动脉造影,1例于前降支植入了1枚支架.ACS患者临床表现复杂,误诊原因多为首诊医师思路狭窄,应充分利用现代影像技术,仔细分析临床症状和体征,可减少误诊死亡的发生.     

放弃治疗面面观

放弃治疗有广义和狭义两种概念,根据临床实践分为主动放弃和被动放弃、单方放弃和双方放弃、明示放弃和暗示放弃、完全放弃和部分放弃。有许多的放弃治疗从患者本人、亲属、医务人员和医疗付费等方面考虑都有积极的意义。在医学伦理学中放弃治疗一直是一个有争议的问题,其道德意义在于体现了唯物主义观点,对人生命的尊重和社会公益原则。对其立法问题有待解决。     

从惊恐障碍看生物心理社会医学模式的必要性和紧迫性

归属于精神医学研究范畴的惊恐障碍患者反复就诊于综合医院内科,频繁使用急救医疗服务,是误诊率最高的疾病之一。本文探讨了惊恐障碍患者去综合医院就诊的必然性和误诊误治的原因及危害性,提出了综合医院医师掌握该病诊治方法,由生物医学模式向生物心理社会医学模式转变的必要性和紧迫性。     

Conscientious objection and emergency contraception

This article argues that practitioners have a professional ethical obligation to dispense emergency contraception, even given conscientious objection to this treatment. This recent controversy affects all medical professionals, including physicians as well as pharmacists. This article begins by analyzing the option of referring the patient to another willing provider. Objecting professionals may conscientiously refuse because they consider emergency contraception to be equivalent to abortion or because they believe contraception itself is immoral. This article critically evaluates these reasons and concludes that they do not successfully support conscientious objection in this context. Contrary to the views of other thinkers, it is not possible to easily strike a respectful balance between the interests of objecting providers and patients in this case. As medical professionals, providers have an ethical duty to inform women of this option and provide emergency contraception when this treatment is requested.     

对外科急腹症诊疗中伦理学矛盾的探讨

由于外科急腹症的特殊性,产生了与其他科室不同的伦理学矛盾。本文探讨了急腹症诊疗中存在的伦理学矛盾和相应对策。在急腹症诊疗过程中,要重视伦理学矛盾产生的原因,完善急腹症诊疗中存在的流程问题,自觉实践医学伦理学的知情同意原则,有助于化解医患矛盾,减少医疗纠纷;同时也要减轻医生工作压力,加强团队合作精神。     

Assessing the Ethics of Medical Research in Emergency Settings: How Do International Regulations Work in Practice?

Different ethical principles conflict in research conducted in emergency research. Clinical care and its development should be based on research. Patients in critical clinical condition are in the greatest need of better medicines. The critical condition of the patient and the absence of a patient representative at the critical time period make it difficult and sometimes impossible to request an informed consent before the beginning of the trial. In an emergency, care decisions must be made in a short period of time, and the more time is wasted, the more the risk of death or severe tissue damage and incapacity increases. Consent requests take time, and so the time period before treatment might put the patient’s life in jeopardy. Not requesting consent before a trial is also contradictory. A person should not be forced to participate in a trial against his or her will. Due to the dark history of medical research previously, international declarations and conventions have set up ethical principles for medical research. They emphasize the autonomy of the research participant—or his or her legal representative—to give a free and informed consent prior to the initiation of research. In the case of a critical emergency, the unconscious state of the patient, the emotional stress of family members or the lack of time to start life-sustaining measures may often restrict the possibilities of communicating with the patient or his/her representative. Therefore, written informed consent is difficult to achieve, and its voluntariness in emergency situations is, at best, open to question. The mortality of patients is high without clinical interventions in emergency research. Random selection of patients is difficult and requires extra work from personnel in the emergency rooms. Recruitment, information and asking for consent may also take time, postpone the initiation of treatment and increase the risk of death and irreversible tissue and organ damage, and therefore be risky for the patient. It is therefore essential that the health care professionals recruiting suitable research participants are well motivated and well trained. Medical research in an emergency setting should always be regarded as an exceptional situation requiring special provisions. Only such research should be done as cannot be done in other conditions. An independent body must approve the research protocol and the ways in which the consent of the participant or proxy are to be sought. In addition, the trial must be expected to result in direct and significant benefit for the research participants. If research without prior consent is not approved, the development of emergency care is threatened. On the other hand, if prior consent is not required, a person could be recruited into a clinical trial against his or her will. Doing good and avoiding harm, and respecting the autonomy of the patient are in conflict in the context of emergency medical research. To develop better medicines for patients experiencing acute medical emergencies, research into such conditions should be allowed. Research participants should have the possibility to participate or refuse to participate in research that may benefit them and other patients. The risk of irreversible damage occurring as the consequence of time delays for seeking consent is unacceptable. A prior wish about participation in clinical trials should be respected, if known. The conditions under which medical research in emergencies can be considered acceptable can be determined and agreed upon nationally and internationally. An earlier version of this paper was presented at The 7th International Conference on Bioethics on “The Ethics of Research in Emergency Medicine”, held on June 2, 2006, Warsaw, Poland.     

Le consentement du patient aux actes de secours lors d’interventions extrahospitalières

The acquirement of a person's consent to the medical care that is proposed to a patient is an absolute basic principle in rescue health care. This is mandatory for first arrival rescuers ; especially since their actions are, in view of the French Emergency Medical Service call centers, considered as being a medical act. The basic principle of consent to first medical care hence imposes itself as a humanitarian act as well as preventing any potential litigation. Nevertheless there are numerous situations where the management of the consent of the person in need of non-medical assistance will present difficulties. It is the necessary to analyze how the rescue health care system can manage and limit the risks s linked to the different situations when treatment is refused by the person in need of such help ; and this so as to respect the individual's dignity whilst not abandoning the needed health care. A collaboration between rescue personnel and the call center coordinating medical doctor is then mandatory especially when no consent is obtained. This will enable the detection of hypotheses where the individual's lucidity is altered and implement proportionately required and helpful measures. It will also equally enable the transmission of efficient information to the patient, in relation to the matter of patient consent and to ensure that the patient is aware of the consequence of his or her decision and that this decision was fully expressed. It would hence be deemed useful that the referenced work frame and recommendations, pertaining to the emergency rescue of a person, established by the General Management of Public Safety and Crisis Management detail more in detail these difficult and delicate situations so as to ensure that rescue personnel can better anticipate them. To conclude were commend a formalization of procedures that could be implemented in situations where a patient that has full mental capacities refuses the proposed health care, and we give the advantages of such a procedure be discussed.     

脑死与放弃治疗

符合医学标准又为亲属认定已死亡者,理应放弃治疗;符合脑死亡标准,应说服亲属同意作放弃治疗决策;对已确无救治希望,或虽经抢救治疗必然发生植物生存状态的极重病例,或已是植物生存状态者,也应作出放弃治疗的决策,除遵循医学原则和生命的价值、伦理原则外,要充分尊重病重的意志。放弃治疗的决策还应考虑到亲属的心理承受问题。     

急诊室濒死病人临床诊治决策的影响因素

正确、合理的临床决策为病人提供理想的诊疗方案。在急诊室濒死病人的诊治过程中,急诊医生应本着以人为本的原则,根据病情的轻重缓急,抓住重点进行紧急处理。其中,病人疾病的性质与预后、疾病严重程度、医生技术水平、医院护理水平、医院的医疗设备与管理水平、诊治费用、医患关系、家属对待诊治的态度、医德医风、政策法规等对医生的临床诊治决策均有不同程度的影响。     

Emergency Research without Consent under Polish Law

Although Directive 2001/20/EC of the European Parliament and of Council of 4 April 2001 on the approximation of the laws regulations and administrative provisions of the Member States relating to the implementation of good clinical practice in the conduct of clinical trials on medicinal products for human use does not contain an exception for emergency situations, and requires the informed consent of a legal representative in all cases where research is conducted on legally competent individuals who are unable to give informed consent, in Poland, emergency research can be conducted without consent. Polish regulations on emergency research can hardly be treated as a result of intentional legislative policy. Our provisions arise from multiple and sophisticated interpretations of different regulations that govern medical experiments on human subjects and clinical trials. These interpretations can be summarized as follows: (1) There are two categories of medical experiments: therapeutic and non-therapeutic experiments. Emergency research without consent may be conducted in the category of therapeutic experiment only (therapeutic experiment consists of the introduction by the physician of new or only partially proven diagnostic, therapeutic or preventive methods in order to achieve direct benefit to the health of the patients, and it can be carried out when hitherto applied methods were ineffective or their effectiveness was insufficient). (2). Emergency research may be conducted without consent if there is a situation of great urgency in which the research subject's life is in danger and there is no possibility of obtaining immediate consent from the research subject him or herself, or from his or her legal representative or guardianship court, and the research subject has not refused to give consent for the participation in an emergency therapeutic experiment. The legal representative or guardianship court shall be provided with all the relevant information concerning subject's participation in an experiment as soon as possible. All projects of emergency research with intent to be done without the research subject's consent must be approved by an independent bioethics committee. Because these five requirements seem to provide insufficient protection for a subject's autonomy and rights it is necessary to add to them two other conditions: (1) the emergency research could not be conducted using other research participants capable of giving informed consent; and (2) informed consent for continued participation in the emergency research shall be obtained from either the participant him or herself or the legally authorized representative as soon as possible (requirement of obtaining deferred consent). A consolidated single Act that will govern all aspects of medical experiments on human subjects, including emergency research, should be prepared and enacted as soon as possible.     

患者报告结局（PRO）在临床疗效评价体系中的应用与思考

现代医疗模式的转变,使得患者对疾病的直接感受,对疗效的评价,成为临床决策和药物安全性评价的重要指标。而PRO量表的问世,使患者有机会真正参与到医疗过程中来,也为临床疗效评价及药物管理提供了珍贵资料。本文将通过什么是PRO、PRO的价值以及PRO的发展近况来对PRO做一个初步的介绍,以便为后来的研究者提供可能的帮助。