Recommendations for Artificial Hydration in a Terminally Ill Cancer Patient

末期癌症病人一般常見的症狀有食慾不振，噁心嘔吐與營養不良等。由於這些症狀伴隨著高致病率與死亡率，往往預後也較差。在病人有胃口且有能力進食時，應給予病人喜歡的食物，照護人員並應注意用餐時的社會心理因素；須提供一個舒適的用餐環境。使用藥物亦可改善食慾，且對妨礙進食的症狀也有緩解效果。人工水份攝取的途徑包含腸道營養及非腸道營養。腸道營養通常由鼻胃管的形式，常常被認為是侵入性相對較小，也可以被用來引流胃裡內容物，以減輕腹脹。非腸道營養可以經由靜脈給予，但因癌末病人常常血管難找，這時候可以考慮較少引發疼痛的皮下途徑。人工水份對具有良好的功能狀態，惡性腸阻塞和鴉片類藥物引起的譫妄的病人幫助最顯著。專家建議人工水份可容許用在Karnofsky score 50%以上或performance status低於2的病人。大多數研究建議一天的水合量為500~1000 ml，並強調依個別症狀治療。例如，當病人已有腹水，肋膜積水，支氣管分泌物增加及周邊性水腫時，應監測病人的水份遲滯症狀有無增加；而且水份也以一天不超過1000~1500 ml為原則。對於有口乾症狀的病人，並無法由人工水份來緩解，時常做口腔護理可改善狀況。如果提供病人攝取人工水份有顯著效益，而且也符合照護計劃時，可以嘗試給予，但必須定期評估其適當性。在無法客觀評估的情況下，應給予限時嘗試治療。再評估人工水份於病人的利害關係，如非必要時，應立即停止。許多病人和家屬往往依賴醫師的專業建議，所以醫護人員有責任不斷的更新對人工水份的知識，才能對病人給予最適合的診療。

關鍵字

人工水份；非腸道營養；腸道營養；癌末病人

並列摘要

Cancer patients are often faced with decreased oral intake, anorexia/cachexia and malnutrition in the last phase of life. These conditions often correspond to a higher morbidity and mortality with poor prognosis. If oral intake is still possible, patients should be encouraged to eat their favorite foods and close attention should be paid to the psychosocial factors of eating. Pharmacologic drugs may be given to increase the appetite or relieve the symptoms that hinder eating.Artificial hydration may be given either enterally or parenterally. Enteral hydration, usually in the form of a nasogastric tube is often considered less invasive and can also be used for drainage of gastric contents to relieve abdominal distention. Parenteral hydration can be given via the intravenous route but when peripheral line access is difficult in a cachexic patient, then the less painful subcutaneous route should be used. Artificial hydration is most beneficial in patients with good performance status, anorexia due to bowel obstruction and opioid induced delirium. Experts suggest that artificial hydration is justifiable in patients with a Karnofsky score of 50% or more or a performance status lower than 2. Most studies recommend a hydration volume of 500~1000 ml/day but strong emphasis is placed on individualized treatment. Patients should be monitored for fluid retention symptoms as hydration of ≥ 1000~1500 ml/day can exacerbate pre-existing ascites, pleural effusion, bronchial secretion and peripheral edema. The sensation of thirst is often not alleviated by artificial hydration but rather by intensive oral nursing care.If artificial hydration is rendered to be beneficial and consistent with the treatment plan, then it can be given under the pretense that the patient must be monitored periodically. A time-limited therapeutic trial may be recommended if patients/families or physicians are indecisive about initiating or forgoing treatment. But if artificial hydration has been proven to be unbeneficial or harmful, then it must be discontinued immediately. Many patients and families often rely on the recommendations of their physician; thus it is the responsibility of physicians to update their knowledge on artificial hydration in order for patients to make the best informed decision.

並列關鍵字

artificial hydration ； parenteral nutrition ； enteral nutrition ； terminally ill cancer patient

國際替代計量

Recommendations for Artificial Hydration in a Terminally Ill Cancer Patient

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