临终关怀 HOSPICE：THE PALLIATIVE CARE
广州市中医医院护理部 曹颖
一、国内外临终关怀发展现状
二、临终病人指导
三、照顾者指导
四、亲属的哀伤护理
一、国内外临终关怀发展现状
? 随着社会的进步、科学技术的发展、人们生活水准不断提高和对卫生保健的需求日益增长，人们不仅希望优生，期望健康长寿，也开始关注死亡问题，重视生命的质量与价值。如何护理处于临终阶段的病人，让他们活得舒适、安祥、尊严和无憾，在充满人间温情、生命价值的温馨气氛中回归大自然，这就是临终关怀--一门新兴的边缘学科，涉及医学、心理学、社会学、护理学、伦理学等学科。
? 据不完全统计，若以每个逝者约有５个直系的亲属、１０个左右的朋友计算在中国每年就有约３５００万人要承受丧亲之痛、７０００万人要承受丧友之痛。
? 实际上，每个具有正常寿命者，都必然地会在某时某刻先品尝到丧亲和丧友之痛苦，然后则体验到自己面对死亡之临终期的极度恐惧。
? 而且，不仅直接面对死亡者要进入所谓临终期，当一个人到了老年时，他或她也就相当于进入了临终期。
? 按国际通行的标准，６０岁以上者可称之为老年人，当一个地区和国家６０岁以上的人口占总人口的１０％以上时，就成为老年型的地区或国家。
? １９９９年１月，新华社公布了中国６０岁以上的老年人已达
１.２亿；到２０５０年，中国将拥有世界近２４％的老年人，约４.５亿，占亚洲的３６％。那时，世界每４个老年人中会有一个是中国的老年人。
? 以目前中国的情况来看，１.２亿以上的人要面对死亡的胁迫；若仍以每人５个亲属、１０个朋友计，则中国每年约有６亿和１２亿人口有间接的死亡问题的困挠。
临终病人的常见心理表现
? 1￡(r)对生活、亲人的留恋。即使已知自己病不能医，仍然对治疗抱有希望。我们应当予以理解、安慰、支持与鼓励。
2．否认自己处于癌症晚期，甚至讳疾忌医。我们应当予以理解，主动帮助病人解决他们的在生活中的困难。
3．对周围的人或事抱着敌视态度，脾气暴躁。对此医生及家属要理解切忌"以牙还牙"。
4．忧郁与轻生。对此我们应当开导、鼓励，并且时时提防发生不测。
5．通情达理、接受现实能平静的面对"另一世界"。我们应该尽量让病人度过一段美好的最后时光。
6．提出最后的愿望。 对此要尽量满足。不能满足的要解释，绝不可抱蔑视、讥讽、嘲笑的态度，要始终保持病人的尊严。
临终病人在临终前有何心理要求
除了在初闻临终讯息时所提到的心理支持外，临终病人在临终前大致还会有下述的心理需求：
? 一、希望维持自己形象的完整，认为自己的形象如果不能像往常一样，就会影响到自己被对待的方式，也会影响到病人对自己的肯定，因此维持自己形象的完整不但是自己自尊的来源，也是让他人尊重的依据；
? 二、强烈的失落感导致强烈的需求感，病人会认为自己过去所拥有的财富、事业、家庭、朋友，都会因着死亡的来临而消失不见，这种强烈的被剥夺的体会，让病人觉得人生在世最后终究一场空，而产生强烈的失落感，在失落的同时，病人对人间一切便产生难以割舍的执着与爱恋，所以有时会让家人感到过度的感情压力；
? 三、孤独产生的关怀需求，虽然病人有时会有静一静的想法，不过基本上病人并不希望这种静一静被误解为喜欢孤独的反应，事实上病人十分担心陷入孤独当中被家人遗弃，只是心中又不想因为害怕孤独而造成家人情感上的负担与不舍，这种又想又怕的反应是家人在提供爱心的支持与关怀时应特别注意的地方；
? 四、不希望生病而成为家人的负担，因为病人本身原先有他自己的独立自主性，也有他自己的贡献价值所在，当然不希望由于生病就成为家人的负担，完全失去自己的自主能力，这时家人就必须从照顾的想法、方式到行动，想办法让病人产生参与感并介入其中，这样病人才能重新自我肯定，积极实践自己的生活。
临终关怀溯源
? 临终关怀（hospice ），始于中世纪，现已成为国际通用的术语。
? 当时，是用来做朝圣者或旅客中途休息，重新补足体力的一个中途驿站。
? 现引申其义，用来指一套组织化的医护方案，帮助那些暂停于人生路途最后一站的人，这个方案的重点是着重于对死亡前病人的疼痛的控制及死亡后家属情绪的支持，抱着对生命的尊重和敬畏，去了解那些病人及家属在最后相处的几个月中，活得更有意义，更有尊严。
? 临终关怀定义：就是指一种照护方案与医生或社会中的巡回医护互相配合，为垂死的病人及其家属提供缓和性和支持性照顾，以及病人死亡后对家属的心理辅导。
二、现代临终关怀的创立
? 追朔早在公元前柏拉图在其《共和国》一书中，就提到家庭对于一个贫苦的个人所能产生的安慰与支持。
? 比利时在中世纪时代某个社区就已设立了"温暖之家"。
? 在一世纪之前，欧洲也有了少数的临终关怀组织，做为垂死病人之家。
? 1967年临终关怀运动的奠基人----英国护士桑达斯创办了世界上第一所临终关怀医院----克里斯多弗医院。
? 70年代中期，美国开始临终关怀的研究工作，同时法、德等发达国家建立起各种形式的临终关怀机构。
美国新港临终关怀院 (1974 年 ) ；
? 加拿大皇家维多利亚安息护理病区 (1975 年 ) ；
? 日本淀川基督教医院附设临终关怀机构 (1984 年 ) 80年代初，前苏联筹建临终关怀机构。
? 1988年天津医科大学创立了临终关怀研究中心，它标志着中国开始了临终关怀的研究与实践。
? 此后，上海市南护理院、北京松堂医院、朝阳门医院第二病区等一批单位陆续介入临终关怀事业。
? 国内外临终关怀现状
1）国外临终关怀状况
美国、加拿大、日本、法国等 60 多个国家和地区相继开展了临终关怀服务和研究。
? 主要杂志有：
– 美国的"死亡教育杂志"；
– 日本的"临终与临床杂志"；
– 加拿大的"安息护理杂志"等。
美国临终关怀的发展
* 1974年，美国首家临终关怀医院建立。
* 财政支持:1982年，国会颁布法令在医疗保险计划（为老年人的卫生保健计划）中加入临终关怀内容。
* 服务机构：从小的、自愿组织发展到各种正规的非赢利和赢利机构。
* 临终关怀的需求量大大增长：如人口老龄化、人们对有尊严地死亡的关注以及各种机构在临终方面费用的增加。
* 美国的临终关怀产业迅速发展：临终关怀计划数量每年以将近17%的速度递增。如今，美国国家临终关怀组织（NHO）在50个州正在运行和计划之中的临终关怀计划超过3100个。仅1998年，美国约有54万病人和他们的家属接受了这种服务。
? 美国临终关怀的现状
（1）人口学统计
根据美国国家临终关怀组织统计，1998年4月，美国65%的临终关怀医院为非赢利机构，16%为赢利机构，4%为政府组织，15%为不确定类型。从组织结构来看，1998年，大约28%的临终关怀机构是独立法人，59%并不是临终关怀医院（例如医院或家庭保健机构），而是隶属于某一法人的机构，13%不确定。
1995年，52%的临终关怀病人是男性，48%是女性。男性病人中，71%是65岁以上，17.2%是50～64岁；10%是18～49岁；1%是17岁以下。女性病人中，74%是65岁及以上，16.7是50～64岁；8.6%是18～49岁；1%是17岁以下。
77%的临终关怀病人死于自己的住宅，19%死于机构，4%的人死于其他地方。在所有接受临终关怀照料计划的病人中，平均存活期为61.5天，即大约为两个月的时间。
（2）临终关怀的财政状况
? 临终关怀是一个节省费用的有效照料方法，因为它由家庭成员、朋友和志愿者在家庭里向病人提供照料，通常不需要费用高昂的技术。
? 节约来源是病人的治疗费、药费、住院费与护理费。
? 临终关怀节省的费用有些是不明显的，例如，许多享受医疗保险的濒危病人经常很晚才接受临终关怀服务，直到他们死亡的前几周或前几天。
? 费用来源：私营卫生保险计划、联邦政府的老年医疗保险计划、国家贫困者卫生援助计划、接受慈善和志愿形式的捐助和社区支持。
（3）临终关怀与医疗保险计划
* 在美国，多数临终关怀照料由医疗保险提供。在医疗保险计划中，临终关怀队为医疗保险病人提供完全的个案处理，包括所有的服务与药物和设备。
* 医疗保险临终关怀福利包括：
·护理服务；·内科医师服务；·药物和生物学；·内科，手术，语言治疗；·家庭保健援助和家务服务；·医疗支持和医疗器械；·短期住院病人照料；·医疗社会服务；·精神，饮食和其他咨询；·专业培训的志愿者；·丧葬服务。
* 临终关怀服务的增长率居各种服务形式增长率之首。
（4）医疗援助计划
医疗援助是联邦和州共同向贫困者提供卫生保健的计划，1999年，美国有43个州以及哥伦比牙地区的医疗援助中包含了临终关怀内容。
? 2） 国内临终关怀状况
1988 年 7 月，天津医学院成立了我国第一个临终关怀研究中心，并于 1990 年建立了临终关怀病房。
– 目前，国内有临终关怀机构约 100 多家，如
– 上海退休职工南汇护理院；
– 北京的松堂关怀院；
– 天津医科大学第二附属医院的"安宁病房"；
– 北京中国医学科学院肿瘤医院的"温馨病房"；
– 沈阳 208 医院的"肝癌病房"等。
? 1992 年，于天津召开"首届东西方临终关怀研讨会"之后，分别于山东烟台、广西桂林、云南昆明等地多次举办"全国临终关怀学术研讨会"。 1993 年成立"中国心理卫生协会临终关怀专业委员会"， 1996 年正式创办"临终关怀杂志"。
? 香港的善终服务始于 1982 年，由九龙圣母医院率先开展"关怀小组"； 1987 年钟淑子女创建了"香港善终服务会"。目前，香港有 13 间医院提供善终服务，如白普理宁养中心、南郎医院、博爱医院等，还有"明天"和"安家舍"二所专门提供善别服务和哀伤关怀的机构。
? 台湾的临终关怀机构主要有： 1990 年建立的马谐纪念医院淡水分院的安宁病房，忠孝医院首创的社会服务室等。
临终关怀服务
* 临终关怀的对象：濒临死亡的人，美国通常是诊断生命只有6个月或不足6个月的病人。
* 临终关怀的目的：
* 通过提供缓解性照料、疼痛控制和症状处理来改善个人余寿的质量。
* 病人的尊严是一个最为关心的问题。临终关怀强调病人和其家属的情感的、心理的、社会的、经济的和精神的需要。
* 既不是治疗疾病或延长生命，也不是加速死亡。
? 主要服务：
1） 服务哲理
(1) 以照料为中心； (2) 维护人的尊严；
(3) 提高临终生活质量； (4) 共同面对死亡。
2）服务内容
(1) 解决基本的生理需要；
(2) 给予相应的心理照护；
(3) 尊重病人的生命、人格和权力；
(4) 对病人家属的关怀与照护。
3）服务类型
(1) 独立的临终关怀院；
(2) 医院附设的临终关怀病房；
(3) 个体式临终关怀；
(4) 居家式临终关怀。
? 专业队伍：由注册护士、内科医生、社会工作者和牧师或其他法律顾问组成的跨学科队伍。需要时，照料服务也提供助手、药剂师、身体治疗，语言治疗和培训过的志愿者。
? 病人和其家属接受一天24小时、一周7天的服务。病人去世后，亲属和朋友可以接受周年丧葬服务。
1995年，根据美国国家临终关怀组织统计，临终关怀病人中60%的人患有癌症，6%患有与心脏有关的病，4%患有爱滋病，1%患有肾脏病，2%有阿尔采默痴呆症，27%患有其他疾病。
临终关怀的障碍
? 在许多国家，包括一些已经有临终关怀计划的国家，都或多或少存在一些妨碍最大限度地发挥临终关怀效益的障碍。
1.核心家庭减少：例如，在许多发展中国家，包括一些发达国家，大家庭支持的减少使得临终关怀照料对于许多在家中接受照料的个人变得更加困难。
2.忌讳谈论死亡：
? 许多个人不愿意承认医生对他们达到临终状态的诊断，他们坚持接受通常被证明是无效的多余治疗。
? 许多家庭成员也对讨论濒死持犹豫态度。
? 当面临不治之症美国人最主要的倾向是：
– （1）有一个获得服务的选择；
– （2）对病人和家属情感的和精神的支持；
– （3）根据病人的意愿控制疼痛；
– （4）病人在自己家中或其一个家庭成员的家中死亡的选择。
? 3.医生不愿下结论：
? 在美国，因为临终关怀的条件包含在医疗保险之中，需要由医院来评估一个病人对临终关怀服务的需要并通知病人获得临终关怀服务。
? 许多医生在需要通知他们的晚期病人的病情时也很犹豫，因为他们不愿打击病人继续治疗的希望。
? 此外，不易准确预测一个病人的余寿时间。
临终关怀发展中的伦理问题
? 2 关注护理而非治疗：
? 对于临终关怀，护理的重点也从生理上转移到心理、社会、精神等方面，而现今的医院又缺乏临床的心理学工作者和社会工作者，使护士在护理过程中遇到无能为力的困难时，投助无门。
? 3 尊重死亡是一个自然的过程，因此不加速也不延迟死亡
? 临终关怀是从各方面努力提高人生命末端质量，使临终者舒适、尊严、安祥地自然死亡，其符合我国社会主义道德要求。
? 安乐死是利用药物或终止维持人生命的措施，加速病人死亡或任病人自行死亡。其存在伦理学与法学诸方面的争议。
? 有学者认为安乐死应属于临终关怀范畴之内，且仅为临终关怀的一小部分。
? 4 协助病人安静地、有尊严地死去；去者能善终，留者能善留
? 病人安静地、有尊严地死去，是临终关怀的结果，但不是终点。
? 古语曰：死者何辜，生者何堪？对所爱的人的死去，我们由震惊而哀恸、绝望，对已故者的感觉由悲转怒，进而出现抑郁等强烈过度的哀伤。
? 在中国现今缺乏社会工作者的情况下，丧亲辅导的任务就落到了护士身上。
? 长期以来，我们往往只单纯注重护士的职业道德的培养，要有爱心、同情心，却忽略了对"抚慰"的知识和技能的培养。当你面对悲痛欲绝的家属时，仅仅有同情心是同样无能为力的。
? 丧亲抚导的课程培训是势在必行的。
六、美国临终关怀对中国的启示
? （1）人口老龄化及计划生育政策使社会对临终关怀的需求将越来越强烈。临终关怀是一个节省费用的有效照料方法，是解决濒危病人家庭照料困难的一个重要途径。使濒危老人尽量获得善终的条件，有尊严和安详地告别人生。
? （2）美国的临终关怀医院尽管有不同的类型，但大多数属于非赢利机构，具有明显的福利性。这也是对我国发展临终关怀机构的一个启示：在发展临终关怀机构的过程中，既要注意多渠道，又要注意其福利性，更多需要由政府出面组织发展。
? （3）濒危病人需要多方面的服务，国情和经济实力决定我国临终关怀仍需强调家庭成员或照料者对濒死者提供富有爱心的帮助。
（4）临终关怀制度化：美国临终关怀服务大部分纳入到医疗保险之中，从而扩大临终关怀服务的覆盖面，使得更多的病人享受这一福利。在具体操作中，美国又制定出一整套严密的规章制度，既通过全方位的服务保证该制度的享受者收益，又完全从现实的财力出发，将提供的服务仅限于经济条件允许的范围之内，确保临终关怀服务健康、有序、持久地运转。
? （5）有效使用医疗资源：
? 接受临终关怀服务可以减少巨额的医疗费用。
? 将少数人的高额无效的费用转移到其他多数人有结果的治疗上，医疗保险费用能够获得最大的效益。
? 适度发展临终关怀对于目前我国的医疗保险制度的改革具有重要的现实意义。
?
二、临终病人指导
指导患者如何度过人生最后阶段：
* 承认自己即将死亡
* 回顾生命的意义
* 接受疾病引起的各种反应
* 正视自己的需求：如需要聊天、或需要安静
* 告诉家人和朋友自己所剩时间不多
* 积极主动参与治疗
* 原谅自己生理上和情感上的缺陷
* 和大家告别
* 找到寄托
* 热情地投入到自己的信仰之中
* 寻求帮助
? 治疗预案：治疗意愿和治疗委托书
? 治疗意愿：写下自己的治疗愿望，以便在弥留之即，自己无法表达时相关人员可以参照执行。
? 治疗委托书：签署一份文件，委托一位值得信任的人当自己无法做决定时，为自己的治疗做决定。
? 为什么需要为自己做治疗预案?
当您昏迷或病危时保障您对自己的治疗有发言权
? 治疗预案的法律保障?
联邦和州的法律均能保障其效力.
非药物止痛的方法：
* 放松疗法、意念疗法、转移注意力、皮肤刺激
* 放松疗法的原理：通过降低肌张力止痛或防止疼痛加剧，可帮助睡眠、恢复体力、减轻焦虑、并促使其他止痛方法更有效。
* 使用放松疗法基本指南:
* 要明白自己的放松能力是会随时变化的，不能强迫自己放松
* 可能要花费2星期练习才能感受到放松疗法的初步成果
* 尝试几种放松方法，找出对自己最有效的。
? 选中一种方法坚持下去，形成习惯。每天做2次，每次5~10分钟。
? 随时注意从头到脚任何一块肌肉是否紧张，放松紧张的肌肉。简便的方法是：吸气/收紧、呼气/放松。
? 如果有肺部疾患，必须先请医生做体检，因为放松疗法需要进行深呼吸。
? 放松练习的特殊体位：尽量选择安静的地点，坐位或卧位。
? 操作方法：
? 目光集中，有节奏的按摩
? Open your eyes and stare at an object, or close your eyes and think of a peaceful, calm scene. With the palm of your hand, massage near the area of pain in a circular, firm manner. Avoid red, raw, swollen, or tender areas. You may wish to ask a family member or friend to do this for you.
? 吸气/收紧、呼气/放松:
? Breathe in (inhale) deeply. At the same time, tense your muscles or a group of muscles. For example, you can squeeze your eyes shut, frown, clench your teeth, make a fist, stiffen your arms and legs, or draw up your arms and legs as tightly as you can.
? Hold your breath and keep your muscles tense for a second or two.
? Let go! Breathe out (exhale) and let your body go limp.
? 减慢呼吸节奏：
? Slow rhythmic breathing:
? Stare at an object or close your eyes and concentrate on your breathing or on a peaceful scene.
? Take a slow, deep breath and, as you breathe in, tense your muscles (such as your arms).
? As you breathe out, relax your muscles and feel the tension draining.
? Now remain relaxed and begin breathing slowly and comfortably, concentrating on your breathing, taking about 9 to 12 breaths a minute. Do not breathe too deeply.
? To maintain a slow, even rhythm as you breathe out, you can say silently to yourself, "In, one, two; out, one, two." It may be helpful at first if someone counts out loud for you. If you ever feel out of breath, take a deep breath and then continue the slow breathing exercise. Each time you breathe out, feel yourself relaxing and going limp. If some muscles are not relaxed such as your shoulders, tense them as you breathe in and relax them as you breathe out. You need to do this only once or twice for each specific muscle group.
? Continue slow, rhythmic breathing for a few seconds up to 10 minutes, depending on your need.
? To end your slow rhythmic breathing, count silently and slowly from one to three. Open your eyes. Say silently to yourself: "I feel alert and relaxed." Begin moving about slowly.
? 可增加一些减慢呼吸节奏的方法:
– 意念控制.
– 戴上耳机听慢速的、熟悉的音乐。
– 逐步放松全身.
– 听柔和的录音带
应用放松技术存在的问题：
? 剧烈疼痛使用放松疗法可能会有困难，可使用一些简单快速的方法，例如节奏按摩或吸气/收紧、呼气/放松练习。
? 如果有"窒息感"，可做深呼吸。
? 有时深呼吸一段时间会感到气短，可做浅和/或慢的呼吸来调整。
? 做放松练习时可能会睡着，如果不想入睡，可坐在硬的椅子上或调好闹钟。
? 你可能会感到沮丧或失落，有时放松后你可能会明白自己潜意识里担心的问题，最好找一个能理解你心情的人谈谈。
? Biofeedback 生物反馈技术
? With the help of special machines, people can learn to control certain body functions such as heart rate, blood pressure, and muscle tension. Biofeedback is sometimes used to help people learn to relax. Cancer patients can use biofeedback techniques to reduce anxiety and help them cope with their pain. Biofeedback usually is used with other pain-relief methods.
Imagery 意念疗法
How Do I Use the Technique of Imagery?
? Close your eyes. Breathe slowly and feel yourself relax.
? Concentrate on your breathing. Breathe slowly and comfortably from your abdomen.
? As you breathe in, say silently and slowly to yourself:
"In, one, two." As you breathe out, say: "Out, one, two." Breathe in this slow rhythm for a few minutes.
? Imagine a ball of healing energy forming in your lungs or on your chest. It may be like a white light. It can be vague. It does not have to be vivid. Imagine this ball forming, taking shape.
? When you are ready, imagine that the air you breathe in blows this healing ball of energy to the area of your pain. Once there, the ball heals and relaxes you.
? When you breathe out, imagine the air blows the ball away from your body. As it goes, the ball takes your pain with it. (Be careful: Do not blow as you breathe out; breathe out naturally.)
? Repeat the last two steps each time you breathe in and out.
? You may imagine that the ball gets bigger and bigger as it takes more and more discomfort away from your body.
? To end the imagery, count slowly to three, breathe in deeply, open your eyes, and say silently to yourself: "I feel alert and relaxed." Begin moving about slowly.
? Problems With Using Imagery
The problems are similar to the ones that may occur with relaxation techniques.
? Distraction 分散注意力
? Distraction means turning your attention to something other than the pain.
? Any activity that occupies your attention can be used for distraction.
? Drawbacks To Using Distraction for Pain Relief 缺点
? tired, irritable, and feel more pain.
? Skin Stimulation 皮肤刺激
Skin stimulation is the use of pressure, friction, temperature change, or chemical substances to excite the nerve endings in the skin.
? Note: If you are having radiation therapy, check with your doctor or nurse before using skin stimulation. You should not apply ointments, salves, or liniments to the treatment area, and you should not use heat or extreme cold on treated areas.
? Skin stimulation is done either on or near the area of pain. You also can use skin stimulation on the side of the body opposite to the pain.
? Massage, pressure, vibration, heat, cold, and menthol preparations are used for skin stimulation.
? Massage 按摩
? For pain relief, massage is most effective when using slow, steady, circular motions. Note: If you are having radiation therapy, avoid massage in the treatment area.
? Pressure 按压
Pressure can be applied with the entire hand, the heel of the hand, the fingertip or the knuckle, the ball of the thumb, or by using one or both hands to encircle your arm or leg.
? Vibration 震动
Vibration over or near the area of pain may bring temporary relief. For example, the scalp attachment of a handheld vibrator often relieves a headache. For low back pain, a long, slender battery operated vibrator placed at the small of the back may be helpful. You may use a vibrating device such as a small battery operated vibrator, a handheld electric vibrator, a large heat-massage electric pad, or a bed vibrator.
? Cold Or Heat 冷敷或热敷
Heat often relieves sore muscles; cold lessens pain sensations by numbing the affected area. Many people with prolonged pain use only heat and have never given cold a try. Some people find that cold relieves pain faster, and relief may last longer.
? For cold, try gel packs that are sealed in plastic and remain soft and flexible even at freezing temperatures. To use heat for pain relief, a heating pad that generates its own moisture (Hydrocolater) is convenient.
? Note: Do not use heat or cold over any area receiving radiation therapy.
? Menthol Preparations 薄荷醇制品
Many menthol preparations are available for pain relief. When they are rubbed into the skin, they increase blood circulation to the affected area and produce a warm (sometimes cool) soothing feeling that lasts for several hours.
? Note: Many menthol preparations contain an ingredient similar to aspirin. A small amount of this aspirin-like substance is absorbed through the skin. If you have been told not to take aspirin, do not use these preparations until you check with your doctor.
? Skin Stimulation Precautions
皮肤刺激注意事项
? Heat and cold can easily damage your skin. It is easy to burn the skin with hot water from the tap or with settings too high on the heating pad. Extreme cold can also burn your skin.
? Never use a heating pad on bare skin.
? Never go to sleep for the night with the heating pad on.
? Be very careful while using a heating pad if you are taking drugs or medicines that make you sleepy or if you do not have much feeling in the area.
? Limit heat or cold application to 5 to 10 minutes.
? Do not use heat or cold over any area where your circulation or sensation is poor.
? If you start to shiver when using cold, stop using it right away.
? Do not use cold so intense or for so long that the cold itself causes pain.
? Do not use heat over a new injury because heat can increase bleeding. Wait at least 24 hours.
? Do not rub menthol preparations over broken skin, a skin rash, or mucous membranes (such as inside your mouth or around your rectum). Make sure you do not get the menthol in your eyes.
? Avoid massage and vibration over red, raw, tender, or swollen areas.
? If skin stimulation increases your pain, stop using it.
As noted earlier, if you are undergoing (or have undergone) radiation treatments, do not use any skin stimulation method without first checking with your doctor or nurse.
? Other Methods of Pain Relief:
? Nerve Blocks
? Transcutaneous Electric Nerve Stimulation (TENS)
? Alcohol
? Acupuncture
? Hypnosis
? Will Marijuana Relieve My Pain?
No. The pain-relieving effects of marijuana are not consistent. Marijuana has been reported to reduce anxiety or control nausea so that the person in pain feels better. However, some cancer patients have reported that smoking marijuana increased their pain. At this time, marijuana is not legally available.
A Dying Person's Guide To Dying
? Here are some pieces of advice to remember in those first few days after you learn the bad news.
? One or two people - probably family members - will make enormous personal sacrifices to help you. If you are married, your spouse is likely to do this, but don't be surprised if others - a daughter, a brother-in-law, or even a friend, step forward to offer extraordinary help. Be grateful, and accept help, from whatever source, graciously.
? Some family members, but especially friends, will treat you differently. Even before you show signs of serious illness, people will have a different look in their eyes as they talk with you. You might consider this patronizing or over bearing. It may be difficult, but it is best to ignore their attitudes and treat them as you always have. They will come around to their normal selves when they get over the shock.
? Happily accept all gifts from family and friends. It makes them feel better and you might receive something you really like and appreciate.
? Don't be afraid to ask to be alone. We need time to be by ourselves. Some family and friends may feel driven to fill your every waking moment with activities; perhaps they are trying to "take your mind off" your impending death, but they may also be doing the same thing for themselves.
? Be your own counsel. No one, including your physician, religious counselor, spouse, or friends can understand 100% what you want and need. It surprised me that some people seemed to "bully" me with advice when they learned that I was terminally ill. We should remember Immanuel Kant's advice to avoid accepting someone else's authority in place of our own powers of reason. We are the ones who should be considering alternatives and making choices. We can, and should, ask for advice. Make telephone calls and read books - but ultimately, we should decide.
? Slow down and ask your family and friends to slow down. There may not be a lot of time, but there is sufficient time in all but the most extreme cases to think, plan, prepare.
? There are things you need to know from your doctors and other health care staff. You need not ask all of the following questions or ask them in this order. Still, these questions deal with crucial issues that need to be addressed and, hopefully, resolved.
? What is my disease?
? Should I seek a second opinion about my disease and my condition?
? What health professional do I especially trust?
? Why am I going into the hospital?
? What are the hospital rules about terminally ill patients?
? What resources are available from the health care community?
? What can I do if it seems that nothing is being done or if I don't understand why certain things are done to me?
? How will I and my family pay for my treatment?
三、对照顾者的支持 ：
? What You Can Do To Be a Supportive Caregiver
? Here are six steps you can take to be an effective caregiver:
? Work and communicate effectively with the patient.
? Support the patient's spiritual concerns.
? Help to resolve the patient's unfinished business.
? Work with health professionals.
? Work with family and friends.
? Take care of your own needs and feelings.
? You should support the person's efforts to deal with the reality of the prognosis emotionally, and this includes efforts to:
? Help the person to accept that he or she has advanced cancer.
? Create a climate that encourages and supports sharing feelings.
? Understand that men and women often communicate in different ways, and make allowances for those differences.
? Be realistic and flexible about what you hope to agree on or communicate.
? Help the patient to deal with anxiety and depression.
? When you and the patient disagree on important issues:
Explain your needs openly.
Choose your battles carefully.
? Let the patient make as many of his or her decisions as possible.
? Support the patient's spiritual concerns.
? Help to resolve the patient's unfinished business.
? Working with Health Professionals
Here are some practical suggestions to keep in mind when you need information and help from health professionals:
? Be clear about what you want, and get to the point as soon as possible.
Make lists of questions and concerns, and have them in front of you when you talk with health professionals.
? Have all the information that health professionals may need ready when you call.
Many of the individual plans in this guide have lists of information you should have when you call for professional help. Try to think ahead about what information medical staff may need, and try to have it ready when you call.
? Write down the answers.
This will ensure that you have the information correct and do not forget it. Have paper and a pencil ready when you call. It is good to keep your questions and answers together in a file or drawer where you can easily find and review them.
? Be firm and straightforward about getting the information and the help that you need.
Health professionals are there to help you be a good caregiver, so make your requests with confidence that you will get the help you need. Feel free to tell them when you do not understand. Remain calm, and speak in a pleasant, polite voice. Being angry usually is not helpful. Being pleasant, firm, persistent, and showing your appreciation usually are the best strategies.
? Working with Family and Friends
? Do not try to do everything yourself. Ask for help.
Family members, friends, clergy, and people who belong to community organizations all can help you. Some can help with planning, and others can help with carrying out those plans and giving support.
? Taking care of your own needs and feelings
You need to be at your best if you are to provide the best care. Therefore, pay attention to your own needs as well as those of the person you are helping. Set limits on what you can reasonably expect yourself to do. Take time off to care for yourself, and ask for help before stress builds.
? It is natural to have strong feelings when you are helping someone with a serious illness. Some common feelings that caregivers have as well as strategies for dealing with them if they become severe are:
? Feeling overwhelmed
Caregivers as well as the person being cared for can feel overwhelmed and confused when they learn that the disease is not responding to treatment or is progressing. Here are some ways to deal with feeling overwhelmed:
? Try not to make important decisions while you are upset.
? Talk over important problems with others who are feeling more levelheaded and rational.
? Anger
There are plenty of reasons for you to become angry while caring for a person with advanced cancer. The best way to deal with angry feelings is to recognize them, accept them, and find some way to express them appropriately. If you do not deal with your anger, it can get in the way of almost everything you do. Here are some ways to deal with your anger:
? Try to see the situation from the other person's point of view, and understand why he or she acted that way.
Express your anger in an appropriate way before it becomes too severe.
? Get away from the situation for a while.
? Find safe ways to express your anger.
Talk to someone about why you feel angry.
? Fear
You may become afraid when someone you care for deeply has a serious illness. You do not know what is in store for this person or for yourself, and you may fear that you will not be able to handle what happens. Here are some ways to deal with your fears:
? Learn as much as possible about what is happening and what may happen in the future.
? Talk with someone about your fears.
? Loss and sorrow:
A serious, life-threatening illness can bring on a great sense of loss and sorrow. You may feel sad that plans you had for the future might not be fulfilled. You may feel the loss of the "normal" person and the "normal" things you did together before the illness. Memories of how he or she used to be may make you sad, and you may feel burdened by more responsibilities that you must handle alone. Here is a way to deal with feelings of loss and sorrow:
? Talk about your feelings of loss with other people who have had similar experiences.
? Guilt
Many people who care for someone with advanced cancer feel guilt at some time during the illness. Here are some ways to deal with feelings of guilt:
? Do not expect yourself to be perfect.
? Do not dwell on mistakes.
Accept your mistakes, and get beyond them as best you can. Repetitive, negative thoughts such as guilt can be controlled by pushing them aside with positive, constructive thoughts.
? Possible Obstacles
Think about what could prevent you from carrying out your plan for being an effective caregiver. Here are some obstacles that other caregivers have faced:
? 1. "He doesn't want to talk about feelings."
? Response: He is the best judge of that. Your job is to make sure the opportunities to listen are there when and if he decides to talk about his feelings.
? 2. "What if she talks about things that I don't want to hear?"
? Response: Even if what are hearing hurts you, consider it in the larger picture of what it means for the patient to be able to express it. Remember that you do not have to resolve everything. You are helping even if you only listen.
? 3. "She won't follow my advice."
? Response: If you are feel frustrated because the person you are caring for will not follow your advice, try to understand how important it is for the patient to retain some control over her life. You may know what is best for her, but realize that your job is to support, not to make decisions for her. If you have a dominant personality or usually have been the one to make decisions in your family, be prepared to practice letting go.
? 4. "I don't have time to take care of my own needs."
? Response: This is the most common reason that caregivers become exhausted. They become preoccupied with problems and do not pay attention to themselves. You will be a better caregiver in the long run if you take the time (especially when stress is high) to get help so that you can do things that you enjoy and relax you.
? 5. "If I don't do it, it won't get done."
? Response: Yes, it will. No one is indispensable. You also should sort out things that really need to be done versus those you would like to see done. It is perfectly acceptable to let some things, such as housework, slide a bit when you take on new responsibilities.
? 6. "I hate asking other people to help me."
? Response: There are two ways around this problem. First, you can get together socially with people who could help and let them volunteer. Second, you could have someone else ask for help for you. Try to make the times when others visit both pleasant and rewarding, then they will want to visit and help.
? 7. "The person I'm helping doesn't want anyone else to help."
? Response: Suggest trying to get help for just a short time, after which you can talk over how it worked. Also, explain to the person you are caring for that you need the help, not him or her.
? Think of other obstacles that could interfere with carrying out your plan.
What additional roadblocks could get in the way of your being a successful caregiver? For example, will the person with advanced cancer cooperate? Will other people help? How will you explain your needs to other people? Do you have the time and energy to carry out these responsibilities?
? Carrying Out and Adjusting Your Plan
? Carrying out your plan
Start using the ideas in this guide immediately. Do not wait until you feel overwhelmed. It is easier to develop good caregiving habits and attitudes early, before problems get out of hand.
? Checking on results
Every week or so, take the time to think about how you are doing as a caregiver. Look through this plan, and ask yourself how closely you are matching the "successful caregiver" that is described.
? If your plan does not work
ask others for help.
四、亲属的哀伤护理
A Guide To Grief
? Grief is a normal response to loss. It can be the loss of a home, job, marriage or a love one. Often the most painful loss is the death of a person you love, whether from a long illness or from an accident or an act of violence.
? This guide will help you understand the grief you and others may feel after a death, whether sudden or anticipated. We hope this guide will help you realize that these feelings are not unusual and things can get better. You are not alone.
? The Grieving Process
Grief is painful and at times the pain seems unbearable. It is a combination of many emotions that come and go, sometimes without warning.
? Grieving is the period during which we actively experience these emotions. How long and how difficult the grieving period is depends on the relationship with the person who dies, the circumstances of the death, and the situation of the survivors.
? The length of time people grieve can be weeks, months, and even years. One thing is certain: grief does not follow a timetable, but it does ease over time.
? Because grief is so painful, some people try to "get over" a loss by denying the pain.
? Studies show that when people don't deal with the emotions of grief, the pain does not go away. It remains with them, and can turn up in unrecognizable and sometimes destructive ways.
? Understanding the emotions of grief and its feeling and symptoms are important steps in healing and in helping others who may be grieving.
? The Feelings and Symptoms of Grief
Experts describe the process of grieving and the emotions of grief in various ways The most commonly described reactions are: Shock, Denial, Anger, Guilt, Depression, Acceptance, and Growth. Some people experience the grieving process in this order. Most often, a person feels several of these emotions at the same time, perhaps in different degrees.
? The Experience of Grief
Grieving people have two choices: they can avoid the pain and all the other emotions associated with their loss and continue on, hoping to forget.
? The other choice is to recognize grieving and seek healing and growth. Getting over a loss is slow, hard work. In order for growth to be possible, it is essential to allow oneself to feel all the emotions that arise, as painful as they may be, and to treat oneself with patience and kindness.
Feel the Pain.
? Talk About Your Sorrow.
Forgive Yourself.
? Eat Well and Exercise.
? Indulge Yourself.
? Prepare for Holidays and Anniversaries.
? Get Help.
? Take Active Steps to Create a New Life for Yourself.
? Helping Those in Grief：如何帮助哀伤的人
? Reach Out to the Grieving Person.
? Listen
? Ask How You Can Help.
? Remember Holidays and Anniversaries.
? Suggest Activities That You Can Do Together.
? Help the Grieving Person Find New Activities and Friends.
? Pay Attention to Danger Signs.
Signs that the grieving person is in distress might include weight loss, substance abuse, depression, prolonged sleep disorders, physical problems, talk about suicide, and lack of personal hygiene.
? Observing these signs may mean the grieving person needs professional help. If you feel this is the case, a suggestion from you (if you feel close enough to the person), or from a trusted friend or family member may be appropriate. You might also want to point out community resources that may be helpful.
? Death can be a painful and permanent loss experience, and one of the hardest from which to recover. Death takes away, but facing it and grieving can result in peace, new strengths and purpose.
? Healing After A Loss
? For The Bereaved: 对丧亲的人
? Express your feelings
? Ask for help when needed
? Be patient with yourself
? Keep yourself healthy
? Be alert to your physical needs
? Learn more about grief
? Trust your ability to heal
? For Those Who Care: 对照顾者
? Be present and available
? Be a good nonjudgmental listener
? Be very patient
? Let the person cry
? Respect the pain of loss
? Continue to provide support after the initial shock has worn off