Dying With Unrelieved Pain-Prescription of Opioids Is Not Enough
Dying With Unrelieved Pain-Prescription of Opioids Is Not Enough
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DOI：
10.1016/j.jpainsymman.2019.07.006
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发表时间：
2019-11-01
影响因子：
4.7
通讯作者：
Schelin, Maria E. C.
中科院分区：
文献类型：
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作者：
Klint, Asa;Bondesson, Elisabeth;Schelin, Maria E. C.
上下文。对疼痛的恐惧与大多数人产生共鸣，尤其是与死亡有关的恐惧。尽管如此，仍有人死于无法缓解的痛苦。在一项全国性的观察性队列研究中，我们量化了死于未缓解疼痛的风险，并调查了危险因素。使用瑞典姑息治疗登记册的数据，我们分析了2011-2015年间的161,762例预期死亡。被调查的危险因素包括死亡原因、死亡地点、没有生命末期谈话(EoL)以及缺乏与疼痛管理专业人员的联系。用改进的泊松回归模型估计死于未缓解疼痛的风险比(RR)和95%可信区间(CI)。尽管97%的病例服用了阿片类药物PRN，但25%的疼痛患者在生命的最后一周报告了未缓解的疼痛。未缓解的疼痛在死于癌症和非恶性慢性病的患者中都很常见。未缓解疼痛的危险因素包括住院死亡(RR=1.84，95%CI 1.79~1.88)与在专科姑息治疗中死亡(RR=1.42，95%CI 1.38~1.45)，与非恶性原因相比死于骨癌(RR=1.13，95%CI 1.08~1.18)或肺部(RR=1.10，95%CI 1.06~1.13)。尽管阿片类药物PRN为疼痛患者开出了几乎完整的处方，但患者死于未缓解的疼痛。医疗保健提供者，尤其是医院，需要更多地关注临终病人的疼痛。EoL对话是一种可以实现的干预。(C)2019年提交人。由爱思唯尔公司代表美国临终关怀与姑息医学学会出版。
Context. Fear of pain resonates with most people, in particular, in relation to dying. Despite this, there are still people dying with unrelieved pain.Objectives. We quantified the risk, and investigated risk factors, for dying with unrelieved pain in a nationwide observational cohort study.Methods. Using data from Swedish Register of Palliative Care, we analyzed 161,762 expected deaths during 2011-2015. The investigated risk factors included cause of death, place of death, absence of an end-of-life (EoL) conversation, and lack of contact with pain management expertise. Modified Poisson regression models were fitted to estimate risk ratios (RRs) and 95% confidence intervals (CIs) for dying with unrelieved pain.Results. Unrelieved pain during the final week of life was reported for 25% of the patients with pain, despite prescription of opioids PRN in 97% of cases. Unrelieved pain was common both among patients dying of cancer and of nonmalignant chronic diseases. Statistically significant risk factors for unrelieved pain included hospital death (RR = 1.84, 95% CI 1.79-1.88) compared with dying in specialist palliative care, absence of an EoL conversation (RR = 1.42, 95% CI 1.38-1.45), and dying of cancer in the bones (RR = 1.13, 95% CI 1.08-1.18) or lung (RR = 1.10, 95% CI 1.06-1.13) compared with nonmalignant causes.Conclusion. Despite almost complete prescription of opioids PRN for patients with pain, patients die with unrelieved pain. Health care providers, hospitals in particular, need to focus more on pain in dying patients. An EoL conversation is one achievable intervention. (C) 2019 The Authors. Published by Elsevier Inc. on behalf of American Academy of Hospice and Palliative Medicine.