Dying with cancer: Patients' function, symptoms, and care preferences as death approaches
Dying with cancer: Patients' function, symptoms, and care preferences as death approaches
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DOI：
10.1111/j.1532-5415.2000.tb03120.x
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发表时间：
2000-05-01
影响因子：
6.3
通讯作者：
Lynn, J
中科院分区：
文献类型：
--
作者：
McCarthy, EP;Phillips, RS;Lynn, J
目的：研究设计：回顾性分析1989年6月至1991年6月和1992年1月至1994年1月结肠癌和非小细胞肺癌患者生命的最后6个月。五个地理位置不同的三级保健学术医疗中心参与了"了解患者预后和对治疗结果和风险的偏好的研究（支持）“项目。参与者：入组SUPPORT的所有患者均患有结肠癌、肝转移或III期或IV期非小细胞肺癌，并在首次住院后1年内死亡。本报告探讨了316 520例转移性结肠癌和747 939例肺癌患者纳入SUPPORT.METHODS：数据收集访谈和图表抽象在几个时间点的支持项目。为了描述死亡进展，我们构建了四个观察窗口，从患者死亡日期开始，到他们进入支持项目的日期或死亡前6个月结束，以先到者为准：（1）死亡前3天，（2）死亡前3天至1个月，（3）死亡前1个月至3个月，（4）死亡前3个月至6个月。对于每种结局，患者向收集数据的所有窗口提供信息。我们描述了随着时间的推移，每个结果的频率分布和报告测试trend.OUTCOME MEASURES：我们检查了几个结果随着时间的推移，包括：在医院度过的天数百分比;预后作为衡量的模型为基础的预后估计6个月的生存;严重程度的疾病作为衡量的急性生理评分;功能状态作为衡量的依赖性的日常生活活动（ADL）;严重的身体和情绪症状，包括增益，抑郁和焦虑;患者对护理的偏好;以及对患者家庭的经济影响。结果：在研究进入后1年内，转移性结肠癌和晚期非小细胞肺癌患者的死亡率很高（分别为61%和80%）。随着癌症患者向死亡发展，他们估计的6个月预后显着下降，他们的疾病严重程度降低。患者的功能状态也随着他们接近死亡而显著下降，使得大多数患者在死亡前3天内具有四个或更多个损伤。随着死亡的临近，癌症患者会经历更多的痛苦和困惑。剧烈疼痛是常见的;超过四分之一的癌症患者在死亡前3至6个月经历严重疼痛，超过40%的癌症患者在生命的最后3天经历严重疼痛。然而，垂死的病人在生命的最后3天只是适度的抑郁和焦虑。随着死亡的临近，病人更喜欢舒适的措施而不是延长生命，大约三分之二的人希望在死亡后3天内放弃复苏。死于癌症的患者的家庭在生命的最后6个月内产生了显着的经济负担，这种负担已经经历了3至6个月前death.CONCLUSIONS：癌症患者生命的最后6个月的特点是功能下降和控制不良的严重疼痛和混乱。虽然病人越来越喜欢舒适护理，因为他们接近死亡，许多人死于严重的疼痛。这些发现强调了改善癌症患者临终护理质量的重要机会。
OBJECTIVE: To characterize the dying experience of patients with cancer over the last 6 months of life.STUDY DESIGN: A retrospective analysis of the last 6 months of life among patients with colon cancer and nonsmall cell lung cancer enrolled in a prospective cohort study from June 1989 to June 1991 and from January 1992 to January 1994.SETTING: Five geographically diverse tertiary care academic medical centers participating in the Study to Understand Patient Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT) Project.PARTICIPANTS: All patients enrolled in SUPPORT who had either colon cancer, metastatic to the liver or stage III or stage TV non-small cell lung cancer and died within 1 year of their index hospitalization. This report examines 316 of 520 patients with metastatic colon cancer and 747 of 939 patients with lung cancer enrolled in SUPPORT.METHODS: Data were collected by interview and chart abstraction at several time points in the SUPPORT Project. To describe progression to death, we constructed four observational windows backward in time beginning with patients' date of death and ending with their date of entry into the SUPPORT Project or 6 months before their death, whichever came first: (1)3 days before death, (2) 3 days to 1 month before death, (3) 1 month to 3 months before death, and (4) 3 months to 6 months before death. For each outcome, patients contributed information to all windows during which they had data collected. We describe the frequency distributions of each outcome over time and report tests for trend.OUTCOME MEASURES: We examined several outcomes over time, including: percentage of days spent in a hospital; prognosis as measured by model-based prognostic estimates of 6-month survival; severity of illness as measured by the acute physiology score; functional status as measured by dependencies in activities of daily living (ADLs); severe physical and emotional symptoms, including gain, depression, and anxiety; patients' preferences for care; and the financial impact on patients' families.RESULTS: The death rate within 1 year of study entry was high among patients with metastatic colon cancer and advanced non-small cell lung cancer enrolled in SUPPORT (61% and 80%, respectively). As patients with cancer progress toward death, their estimated 6-month prognosis decreases significantly and the severity of their disease worsens. Patients functional status also declines significantly as they approach death, such that most patients have four or more impairments within the 3 days before death. Patients with cancer experience significantly more pain and confusion as death approaches. Severe pain is common; more than one-quarter of patients with cancer experience serious pain 3 to 6 months before death and more than 40% were in serious pain during their last 3 days of life. However, dying patients are only modestly depressed and anxious during their last 3 days of life. As death approaches, patients favor comfort measures over life-extension, and about two-thirds want to forego resuscitation within 3 days of death. Families of patients dying with cancer incurred significant financial burdens during the last 6 months of life, and much of this burden was already experienced by 3 to 6 months before death.CONCLUSIONS: The last 6 months of life for patients with cancer is characterized by functional decline and poorly controlled severe pain and confusion. Although patients increasingly prefer comfort care as they near death, many die in severe pain. These findings highlight important opportunities to improve the quality of care at the end of life for patients dying with cancer.