Download SPACE_Care_of_dying

超越痛苦‧死亡寧定
Care of the dying
謝俊仁
Tse Chun Yan
Depersonalisation of death & dying
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Even the care for the dying is “system
by system”, “organ by organ”
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Death as enemy! Death as failure!
What is palliative care ?
WHO definition:
http://www.who.int/cancer/palliative/en/
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Affirms life and regards dying as a natural process
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Neither hastens or postpone death
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Provides relief from pain and other distressing symptoms
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Integrates physical, psychological, social and spiritual aspects of care
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Support the patients to live as actively and fully as possible
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Support the family during the illness and during grief
By multidisciplinary team approach
The suffering of whole person
A personal and unique experience
身
PHYSICAL
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疼痛、嘔心、氣促、咳嗽、食慾不振、便秘、失眠、
口乾、水腫、疲倦、四肢無力、腹脹、消瘦等
心
• 擔憂、緊張、傷心、消沈、內咎、抑鬱、無助、逃避、
無奈、失望、矛盾、孤獨、不忿、期待早死等
PSYCHOLOGICAL
社
SOCIAL
靈
SPIRITUAL
• 失去工作能力、不能照顧家人、減少外出、怕見
朋友、要依賴他人、失去外表、失去自我形像等
• 對人生存疑、懷疑生命的價值、如何尋找活著的意義
How a patient tells you What she is suffering from
‘It hurts everywhere’
‘I don’t look the same now’
‘I’m no longer a good mother’
‘I can’t do what I used to do’
‘I am useless’
‘I have no future’
‘I haven’t told them I’m sorry’
‘I would rather die’
‘Nobody can understand me’
‘Why do I have to suffer ?’
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multiple symptoms
loss of image
loss of role
loss of function
loss of dignity
hopelessness
broken relationships
loss of will to live
disconnectedness
meaninglessness
How to help the patient?
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Breaking bad news
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Decisions on specific treatments towards the
disease
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Control of physical symptoms
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Psychosocial and spiritual support
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Decisions on life sustaining treatment
Breaking bad news
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Why should we let the patient know the
diagnosis?
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Cultural factors?
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How should we do it?
Decisions on specific treatment towards
the disease
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A balance of benefit, burdens and risk
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Respect the patient’s choice
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Problem of cost
Control of physical symptoms
Pain assessment
 Diagnosis of the cause of pain
 Pain control –
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Analgesic ladder
Regular dosage
Myths about the use of strong analgesics
Other medications
Other modalities of treatment
“Total pain”
Suffering as a personal experience
Pain is more likely to cause suffering if..
 The more intense it is
 The more unpredictable it is
 I believe that pain cannot be controlled
 I believe that the pain has no end
 I believe that no one believes in my pain
 I believe that it is threatening my life
 I fail to make any sense out of the pain
Psychosocial and spiritual support
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Multidisciplinary team approach
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Examples of specific therapies
◦ Meaning centered therapy
◦ Dignity therapy
A meaning of personal significance & importance
Transcendence to a wider landscape
“My love for my family will last..
They will remember me as who I am,
what I have done for them in the past,
and not what I cannot do today…..”
Transformation
“But this illness reminds me of the
important things in life…”
Feeling
“I feel sad about leaving my loved ones”
Sensation
“My body is getting weaker and weaker”
Cognition
“I have a cancer which is not curable”
Decisions on life sustaining treatment
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“Do-not-resuscitate” orders
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Forgoing other forms of life sustaining
treatment
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A balance of benefit, burdens and risk
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Respect the patient’s choice
Advance care planning
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A discussion between the patient, family
and clinical team on how the patient
should be treated at the end of life, which
may include discussions on
◦ Individual wishes, personal values, and goals
for care
◦ Advance refusals of life sustaining treatment
◦ Place of death
Care of the family members
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During the illness
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During grief
(separate talk on this)
Thank you!