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作者：Laurie Barclay, MD
出处：WebMD医学新闻
May 3, 2007 — 根据一项发表于5月3日于西雅图华盛顿美国老人医学会（AGS）年会发表的研究结果显示，对于罹患末期癌症的病患，在生命的最后一周进行积极治疗与死亡时生活品质较差有关，且较不能于病患希望的场所过世。
主要作者Gabriel K. Silverman硕士，他是一位卡内基美隆大学社会与判断部门、宾州匹兹堡大学医学院的医师/博士研究生，他向Medscape表示，我们发现这些癌末病患在他们的最后一周接受积极性治疗的数目越多，他们会体验到越多精神与生理上的压力；在临终前没有接受积极性治疗的病患，将近90%死于他们所偏好的地点，然而，这仅发生在接受两种以上这些治疗三分之一的病患身上；我们发现，使用安宁疗护的时间与预后差有关。
该项研究是the Coping with Cancer研究的一部份，其访谈了243位癌末病患与其照护者，在病患过世后，最了解有关于病患生命最后一个星期的非正式照护者（例如配偶或是成人子女）、或是正式照护者（例如护理人员），报告这段时间所接受的积极治疗；积极治疗的定义为，在加护病房接受的照护、接受呼吸器治疗、复苏、灌食管、非缓和化学治疗、与抗生素；预后评估包括所接受的安宁疗护时间长度，与许多生活品质评估。
在校正病患的性别、年龄、种族、与资讯来源（非正式或是正式照护者），最后一个星期所接受的积极性治疗数目与精神压力（P=0.003）、更多的生理压力（P<0.0001）、较低的整体死亡品质（P=0.03）有关、且死于病患所偏好场所的机率较低（P<0.0001）。
相对的，在校正上述所有变项后，接受较长时间的安宁疗护与较低的生理压力（P<0.0001）、较高的整体死亡品质（P=0.01）有关，而死于病患所偏好场所的机率较高（P<0.0001）。
Silverman医师表示，病患花在安宁疗护的时间越多，死亡的品质越好；举例来说，接受至少五周安宁疗护的病患，相较于那些仅在安宁疗护待不到一个星期的病患，其在生命最后一周的生理压力较少，且那些根本没有接受安宁疗护的病患，在生命最后一周的生理压力是最大的；这些结果显示，当病患临终时，应该谨慎使用积极性治疗，且仅在病患或其代理人完全了解的情况下进行。
根据匹兹堡大学医学院缓和照护与医学伦理部门主任Robert M. Arnold医师表示，他同时也是Leo H. Criep病患照护主席，该试验的一项限制是其无法判断因果关系，Robert M. Arnold医师并未参与这项研究，仅提供Medscape独立的评论。
Arnold医师表示，这项研究结果显示，积极治疗与精神及生理压力之间的关系，但是这可能是因为人们处于很大的压力下会寻求更多的治疗，而不是因为治疗本身造成压力；显然地，需要更多的研究，同时必须增加缓和照护医师于生命终点时的角色。
Silverman医师指出，有关于预后、照护目标、与治疗偏好，包括安宁疗护的选择，都应该与更多病患讨论，且于疾病进程较早期时进行；他的团队目前正前瞻性地评估医师与病患之间的对话，是否可以用来预测病患于临终时接受治疗的积极度，以及接下来的治疗，是否会影响其亲友成员对于失去亲人的反应。
Arnold医师的结论是，身为一位医师，如果我有一位于临终前希望积极、维生性照护的病患或是亲友，我会认为这是病患或是照护者不安的警示；病患与其亲友在临终前经常是受苦的、悲伤的、或是感到压力的，且当于医疗院所临终前他们可能会希望积极治疗会协助他们度过这段痛苦的时间，但是经常是不行的。
国家精神健康机构、国家癌症机构、一项国家卫生研究院的博士前研究赞助计划、与精神癌症与缓和照护研究中心、达那-法柏癌症研究治疗中心赞助这项研究；Silverman与Arnold医师表示无相关资金上往来。
原文：
Aggressive Treatments at End of Life Linked to Worse Quality of Death for Cancer Patients
By Laurie Barclay, MD
Medscape Medical News
May 3, 2007 — For patients with advanced cancer, aggressive treatment in the last week of life is linked to a worse quality of death and less likelihood of dying in the place of the patient's choice, according to a presentation on May 3 at the American Geriatrics Society (AGS) annual meeting in Seattle, Washington.
"We found that the greater the number of aggressive treatments these advanced cancer patients received in their last week of life, the more psychological and physical distress they experienced, as reported by family members or nurses who were with them at that time," presenter and lead author Gabriel K. Silverman, MS, an MD/PhD student at the Department of Social and Decision Sciences, Carnegie Mellon University, and the University of Pittsburgh School of Medicine in Pennsylvania, told Medscape. "Of patients who received no aggressive treatments in the days preceding their death, nearly 90% died in their preferred location, while this was true of only about a third of patients receiving two or more of these treatments. We found the reverse pattern of outcomes associated with duration of hospice use."
As part of the Coping with Cancer study, 243 advanced cancer patients and their caregivers were interviewed. After the patient's death, the primary informal caregiver (e.g., spouse or adult child) or formal caregiver (e.g., nurse) most knowledgeable about the patient's last week of life reported which aggressive treatments the patient received during that week. Aggressive treatments were defined as intensive-care-unit stay, ventilator support, resuscitation, feeding tube, nonpalliative chemotherapy, and antibiotics. Outcome measures included the duration of hospice care received and various measures of quality of death.
After adjustment for the patient's sex, age, race, and the source of the report (informal or formal caregiver), the number of aggressive treatments received in the last week of life was associated with more psychological distress (P = .003), more physical distress (P < .0001), a lower overall quality of death (P = .03), and a lower probability of dying in the patient's preferred place (P < .0001).
In contrast, receiving a longer duration of hospice care was associated with less physical distress (P < .0001), a higher overall quality of death (P = .01), and a greater probability of dying in the patient's preferred place (P < .0001), after adjustment for the variables listed above.
"The more time patients spent under hospice care, the greater their quality of death," Mr. Silverman said. "For example, patients who received at least 5 weeks of hospice care were in less physical distress in their last week of life than those who lived less than a week with hospice, and those who received no hospice at all were in the most physical distress at the end of their lives. These results suggest that when patients are actively dying, the use of aggressive treatments should be considered with caution and only pursued with the full understanding of patients or their surrogate decision makers."
A limitation of this study is that it cannot determine causality, according to Robert M. Arnold, MD, the Leo H. Criep Chair in Patient Care and Chief, Section of Palliative Care and Medical Ethics at the University of Pittsburgh School of Medicine. Dr. Arnold was not directly involved in this study but provided independent commentary for Medscape.
"This study shows an association between aggressive treatment and psychological and physical distress, but that might be because people who are more distressed ask for more treatment, rather than because the treatment itself is causing distress," Dr. Arnold said. "More research is clearly needed, as is greater use of palliative care doctors at the end of life."
Mr. Silverman pointed out that discussions about prognosis, goals of care, and treatment preferences, including the option of hospice care, should occur with more patients and earlier in the course of the disease. His group is now prospectively evaluating whether doctor-patient communication predicts aggressiveness of care at the end of life, and whether these treatments, in turn, affect the bereavement adjustment of close family members.
"As a doctor, if I had a patient or family who wanted aggressive, life-sustaining care toward the end of their life, I would view it as a red flag warning of patient or caregiver distress," Dr. Arnold concluded. "Often patients and their families are suffering, sad, or distressed at the end of life, and when dying occurs in medical settings they may hope that aggressive treatment will help the suffering, but often it doesn't."
The National Institute of Mental Health, National Cancer Institute, a predoctoral National Institutes of Health training grant in aging research, and the Center for Psycho-Oncology and Palliative Care Research, Dana-Farber Cancer Institute, supported this study. Mr. Silverman and Dr. Arnold report no relevant financial relationships.
AGS 2007 Annual Scientific Meeting: Abstract P4. Presented May 3, 2007.