ICU伦理问题的分析与对策

ICU伦理问题主要集中在：ICU的过度医疗现象;ICU忽视医学伦理的问题;ICU患者知情同意权的相关问题;长期入住ICU患者的经济伦理问题;ICU终末期患者治疗策略的伦理问题;ICU医护人员职业倦怠的相关伦理问题。通过对上述伦理问题的分析,提出了解决问题的伦理路径,主要包括以下几方面：加强医疗收费的合理性,防止出现过度医疗现象;加强ICU医护人员的责任感,提高医方的公信力;加强医患间的沟通,重视患方的知情权;对ICU临终患者坚持道义与功利相结合的原则;改善ICU进出标准,科学利用稀缺资源;加强ICU医学伦理知识的普及,缓解医患矛盾。     

ICU护士第二受害者经历与支持影响因素分析

采用一般资料调查表、不良事特征调查表、组织支持感量表、心理弹性量表和第二受害者经历与支持量表对大连市11所医院428名ICU护士进行调查。结果显示,ICU护士作为第二受害者经历与支持总分为（82.84±13.58）分;岭回归结果显示,是否经历了护理部层面的分析讨论或汇报、情感性支持、工具性支持、自强型是ICU护士第二受害者经历与支持水平的影响因素（β=−3.177～0.587,P＜0.05）,共同解释23.3%的变化。ICU护士发生不良事件后的心理体验情况不容乐观,医院管理者需重视ICU护士的负性情绪,可通过增加组织支持感和提升心理弹性水平以减轻第二受害者的痛苦体验。

     

The acute psychobiological impact of the intensive care experience on relatives

There is a growing awareness amongst critical care practitioners that the impact of intensive care medicine extends beyond the patient to include the psychological impact on close family members. Several studies have addressed the needs of relatives within the intensive care context but the psychobiological impact of the experience has largely been ignored. Such impact is important in respect to health and well-being of the relative, with potential to influence patient recovery. The current feasibility study aimed to examine the acute psychobiological impact of the intensive care experience on relatives. Using a mixed methods approach, quantitative and qualitative data were collected simultaneously. Six relatives of patients admitted to the intensive care unit (ICU) of a District General Hospital, were assessed within 48 h of admission. Qualitative data were provided from semi-structured interviews analysed using interpretative phenomenological analysis. Quantitative data were collected using a range of standardised self-report questionnaires measuring coping responses, emotion, trauma symptoms and social support, and through sampling of diurnal salivary cortisol as a biomarker of stress. Four themes were identified from interview: the ICU environment, emotional responses, family relationships and support. Questionnaires identified high levels of anxiety, depression and trauma symptoms; the most commonly utilised coping techniques were acceptance, seeking support through advice and information, and substance use. Social support emerged as a key factor with focused inner circle support relating to family and ICU staff. Depressed mood and avoidance were linked to greater mean cortisol levels across the day. Greater social network and coping via self-distraction were related to lower evening cortisol, indicating them as protective factors in the ICU context. The experience of ICU has a psychological and physiological impact on relatives, suggesting the importance of identifying cost-effective interventions with evaluations of health benefits to both relatives and patients.     

ICU治疗实践的伦理问题辨析

从重症加强护理病房(intensive care unit, ICU)医生角度出发,通过工作中所接触的典型案例,提出患者入住ICU三个不同时间所产生的伦理问题,包括：患者入住ICU前,不同患者实际情况与ICU收治标准不符,作为ICU医生应在尊重患者自主意愿前提下,最大限度地完成治疗;患者于ICU治疗期间,ICU综合征及ICU后综合征产生原因及解决方案,家属代表患者做医疗决定时面临的两难抉择,ICU医生应该做好医患沟通工作,从多角度实施人文关怀;ICU治疗终末期患者生命尊严和短暂生存之间的选择,ICU医生应建议家属接受缓和医疗并介绍器官捐献参与过程中伦理原则。

     

镇静与镇痛在ICU机械通气患者中的应用变化

探讨ICU内机械通气患者应用镇痛剂、镇静剂及肌松剂的情况及其对机械通气和预后的影响。回顾性分析我院中心ICU2006年、2007年收治的244例行有创机械通气治疗超过48h患者的临床资料,并将患者分为2006年组和2007年纽,用统计软件分析患者在年龄、性别、入ICU时APACHEⅡ评分、血糖、血浆白蛋白、基础疾病,气管插管时间、机械通气时间、ICU住院天数、镇痛与镇静剂应用的时间、机械通气时是否使用肌松剂、Ramsay评分及病死率方面是否存在差别。统计分析显示2006年组和2007年组在年龄、性剐、入ICU时APACHEⅡ评分、血糖、血浆白蛋白、是否使用肌松剂及基础疾病方面无差别;与2006年组相比2007年组患者气管插管时间、机械通气时间及ICU住院天数均缩短,镇痛与镇静剂应用时间均缩短,Ramsay评分降低,病死率下降。提示对机械通气的危重症患者应合理使用镇痛剂与镇静剂。     

ICU中机械通气患者胃肠道功能障碍与预后的关系

为了探讨重症加强治疗病房机械通气患者胃肠道功能障碍与预后的关系,回顾性分析了我院中心ICU收治的68例非胃肠道疾病且行有创机械通气治疗超过48h患者的临床资料,并将患者分为胃肠道功能障碍组和非胃肠道功能障碍组,用统计软件分析发生胃肠道功能障碍的相关临床因素及发生胃肠道功能障碍后对病死率的影响。结果显示,统计分析显示胃肠道功能障碍组和非胃肠道功能障碍组在机械通气天数、APACHEⅡ评分、MODS的发生率、病死率间存在明显差异。因此,对危重病患者应重视其胃肠道功能障碍的防治。     

ICU不能回避的课题：生命支持系统的撤除

ICU内生命支持系统不但应得到充分的使用,在适当的时候也应予以撤除。“适当”包括两方面含义：患者已经康复和患者已无可能康复,共同点在于继续使用生命支持系统已经无助手患者及家人的福祉。患者终末期管理已成为ICU专门领域,与其他专门领域同样需要相当的知识与能力。     

ICU医护沟通与协作的现状与思考

许多研究表明ICU医护之间的沟通与协作存在重大问题,特别是在临终决策中存在分歧。护士的作用经常被忽视。加强医护之间的沟通与协作有助于提高医疗质量并改善医护、患者及家庭满意度。许多旨在改善沟通与协作的措施已经证实有效并可应用于临床实践,并应对此进行更深一步的研究。     

ICU患者出院后重返工作岗位相关研究进展

通过查阅国内外文献,从综合ICU患者出院后重返工作岗位相关概念及现状、影响因素（包括人口统计学因素,社会心理学因素,院前、院内、院外相关因素）及干预措施（包括早期康复活动、ICU患者出院后随访、社会支持）四个方面进行综述,同时提出了促进ICU出院后患者重返工作岗位的建议及未来展望,旨在为学者开展ICU出院后患者重返工作岗位相关研究提供参考、为临床工作人员促进ICU患者康复提供护理干预建议,也为社会工作者提供就业指导。

     

Developing the couple perspective in parenting support: evaluation of a service initiative for vulnerable families

The importance of the relationship between parents is frequently underestimated by those designing and developing services to support parents in bringing up their children. Instead, the primary focus of recent family support initiatives in the United Kingdom has been on improving parenting skills. This article describes the outcomes of a project designed to maximize the effectiveness of parenting support to vulnerable families through sensitizing the workforce of a community‐based adult mental health agency to take account of the parental couple in providing postnatal support groups, parenting workshops and relationship counselling. Evaluating outcomes from these services suggests that a couple orientation adds significant value to the effectiveness of parenting support.     

ICU生命末期患者死亡质量量表的汉化及信效度评价

为了翻译并修订重症监护病房生命末期患者死亡质量量表(QODD-3.2A),形成中文版QODD-3.2A,并对其进行信效度检验,先采用Brislin翻译模式对QODD-3.2A进行翻译、回译、专家咨询、预调查后形成中文版QODD-3.2A,之后采用便利抽样方法,对湖北省两所综合医院182例死亡患者的死亡质量进行调查并评价其信效度。通过分析,中文版QODD-3.2A量表有6个维度,共24个条目,累计方差贡献率为67.47%,总量表的Cronbach'sα值为0.891,折半系数为0.801,量表水平的内容效度指数为0.94。中文版QODD-3.2A具有较好的信效度,可作为国内ICU生命末期患者死亡质量的评估工具。     

ICU患者外出检查风险分析与对策

为了探讨ICU危重患者外出检查风险的原因,从而降低ICU危重患者外出检查风险,本文通过对312例ICU患者外出检查风险因素进行讨论分析,研究降低风险的对策,即在规范ICU患者外出检查流程、做好检查前准备和注意途中安全及返回后的护理,结果提示285例患者无意外发生,安全返回病房,其余27例患者存在一定风险,但在相应处理措施下均安全返回病房。     

ICU向患者家属开放的理论研究

ICU实行的基本是封闭式管理,这不仅带来了一些伦理问题,也容易引发医疗纠纷,从伦理学的需要、预防医疗纠纷、改善医患关系等方面探讨ICU向患者家属开放的必要性,分析开放存在的问题,论证了ICU向患者家属开放的可行性。     

Perceived organizational support, organizational commitment and psychological well-being: A longitudinal study

Using longitudinal data (N = 220), we examined the contribution of perceived organizational support and four mindsets of organizational commitment (affective, normative, perceived sacrifice associated with leaving and perceived lack of alternatives) to employee psychological well-being. In order to assess the contribution of support and commitment independently from workplace stressors, we controlled for the effects of role ambiguity, role conflict and role overload. Analyses showed affective organizational commitment to mediate a positive relationship between perceived organizational support and well-being. In addition, perceived organizational support negatively related to perceived lack of employment alternatives which, in turn, was negatively related to well-being. Normative commitment and perceived sacrifice associated with leaving were unrelated to well-being. The implications of these findings are discussed under the lenses of social exchange and conservation of resources theories.     

新生儿重症监护病房患儿家属心理状况分析

探讨新生儿重症监护病房（NICU）住院患儿家属的心理状况及影响因素。采用焦虑自评量表（SAS）及自行设计的调查问卷对190名NICU住院患儿家属进行调查。结果显示患儿家属表现出不同程度的焦虑,与全国常模（29．78±0．46）相比,其焦虑情绪标准分49．54±1．07,高于常模组（P〈O．05）。影响因素主要包括文化水平、家庭人均收入及患儿病情严重程度等。患儿父母关注的主要问题包括：病情严重程度、预后、医护人员解释病情满意度及病房探视制度。笔者认为医护人员应加强与患儿家属的有效沟通,满足其心理需求,提高医疗护理质量,促进医患关系和谐。     

Psychological support for people with dementia: A preliminary study

Aim/Purpose

Evidence suggests nonpharmacological therapies could improve quality of life in people with Alzheimer's disease (Olazaran et al., 2010). This study aimed to explore attitudes to, and acceptability of, psychological support for people with mild dementia, from their perspective.

Design/Methodology

Semi‐structured interviews were conducted with five people identified from secondary care services. Questions concerned the experience of being diagnosed, experience of support services and their opinion of alternative support options. Interviews were audio‐recorded, transcribed and analysed using thematic analysis.

Results/Findings

Three main themes were identified: loss, coping mechanisms and support. Loss of physical abilities was associated with loss of identity and place in the community. Coping mechanisms included asserting control, and growth and development, including engaging in new activities or using humour. Individual needs and preferences were key to effective support. Social aspects of support and opportunities to talk about their feelings were valued by participants. Counselling, mindfulness and group‐based activities, including walking and gardening, were viewed positively. Support from admiral nurses or specialist nurses tended to be viewed in terms of physical health needs, and most needed in later stages of dementia.

Research Limitations

Limitations include the small sample size, potential inaccuracies acknowledged by participants regarding recollections of events and researcher bias in hoping that psychological support would be well received.

Conclusions/Implications

Talking therapies and psychosocial interventions are acceptable sources of support. Person‐centred support which considers personal preferences and abilities can support people to live well with dementia.     

体验式教学在ICU护士人文执业能力培养中的应用

按照护士人文执业能力概念架构,将护士人文执业能力培养分解为心理调适能力、自我管理能力、人际沟通能力、人文关怀实践能力、伦理与法律实践能力5个核心概念,并将其融入在体验式教学课程中,应用于ICU护士人文执业能力的培训中。通过引导式思考、情境体验、实践反思、质量评价等方式,开展相关培训。对比试验组和对照组的结果,发现体验式教学法能为ICU护士提供对人文执业能力理解的思路与方法,进而提升护士人文执业能力。

     

Psychological support post-release of humanitarian workers taken hostage: the experience of the International Committee of the Red Cross (ICRC)

ABSTRACT

Following release, former hostages face many challenges and may struggle to regain control over their lives. Research and evidence on how to effectively address the needs of hostages during their release and afterwards is lacking. The International Committee of the Red Cross has extensive experience in managing hostage situations and has strengthened the practice of care offered to its own affected staff by developing an inter-professional comprehensive seven phase care model adapted to incidents of extended duration with multiple stressors. This includes strong coordination between the different actors involved, combined with long-term peer, social and organisational support, as well as workplace reintegration with guidance by colleagues, and specialised counselling when necessary, to ensure positive outcomes, and minimise permanent sequelae.     

预立医疗照护计划在重症医学科中的应用研究进展

基于目前我国医疗压力较大,过度治疗现象突出等问题,站在现代医学观念和辩证思维角度来思考如何合理且有效地利用现有的医疗资源,减少不必要且增加患者痛苦的治疗,减轻患者家庭负担,让患者有尊严地离开。同时,借鉴国外经验结合我国文化背景对预立医疗照护计划的可行性和必要性进行阐述,对国内外预立医疗照护计划实施的现状进行对比,并分析国内外预立医疗照护计划实施差异的原因,提出针对性的措施,以期为我国重症医学科推行预立医疗照护计划提供建议,促进安宁疗护的进一步发展。     

Determinants of social support among low-income mothers: a longitudinal analysis

This study examined the reciprocal relationships between perceived mastery, stress, and three functional areas of social support: tangible support, informational support, and belongingness support. Data were collected during two face-to-face interviews with a sample of low-income, primarily African-American mothers, conducted approximately 1 year apart. Consistent with predictions, initial levels of mastery predicted higher subsequent levels of instrumental social supports (tangible and advice support), but were unrelated to belonging support. Conversely, initial levels of tangible support were predictive of later mastery. Perceived stress did not account for any additional variance in subsequent support, although initial levels of belonging support only did predict reduced stress at Time 2. Results suggest that successful attempts to garner instrumental supports is an important contributor to individuals' sense of self-efficacy, at the same time, self-efficacy leads to more successful use of existing social support systems. These findings point to the importance of having both available tangible support networks as well as close emotional supports for low-income parents. The importance of using longitudinal, multidimensional analyses to better understand the social support process is discussed.