{"id":408,"date":"2022-03-13T11:24:19","date_gmt":"2022-03-13T08:24:19","guid":{"rendered":"https:\/\/tatd.org.tr\/geriatri\/?p=408"},"modified":"2022-03-13T11:24:19","modified_gmt":"2022-03-13T08:24:19","slug":"yasli-hastada-yasam-sonu-sorunlari-ve-yonetimi","status":"publish","type":"post","link":"https:\/\/tatd.org.tr\/geriatri\/genel\/yasli-hastada-yasam-sonu-sorunlari-ve-yonetimi\/","title":{"rendered":"Ya\u015fl\u0131 Hastada Ya\u015fam Sonu Sorunlar\u0131 Ve Y\u00f6netimi"},"content":{"rendered":"<p>\u2018<em>\u0130nsanlar\u0131n nas\u0131l \u00f6ld\u00fc\u011f\u00fc, ya\u015fayanlar\u0131n an\u0131s\u0131nda kal\u0131r\u2019<\/em><\/p>\n<p>Dame Cecily Saunders<\/p>\n<p><strong>Ya\u015flanma \u0130le \u0130lgili Genel Bilgiler<\/strong><\/p>\n<p>D\u00fcnyada ya\u015fam beklentisi gittik\u00e7e artmaktad\u0131r. Artan ya\u015fl\u0131 n\u00fcfusu ile paralel olarak acil servis ba\u015fvurusu ve acil servislerde \u00f6l\u00fcm oranlar\u0131 da artmaktad\u0131r (1,2). Acil servise ba\u015fvuran ya\u015fl\u0131lar\u0131n bir k\u0131sm\u0131nda palyatif bak\u0131m ihtiya\u00e7lar\u0131 vard\u0131r, ancak birincil odak noktas\u0131n\u0131n canland\u0131rma ve hayat kurtarma oldu\u011fu bir ortamda bu ihtiya\u00e7 g\u00f6zden ka\u00e7abilir (1,3). Bu gibi durumlarda, acil servislerde palyasyon ve ya\u015fam sonu bak\u0131m\u0131na ili\u015fkin kararlar\u0131n al\u0131nmas\u0131 ve yeni stratejilerin geli\u015ftirilmesi gerekir (4).<\/p>\n<p>Ya\u015fam\u0131n uzamas\u0131, kronik progresif hastal\u0131klar\u0131n iyi y\u00f6netimi acil servis klinisyenleri i\u00e7in palyatif ve ya\u015fam sonu bak\u0131m becerileri geli\u015ftirmelerini zorunlu k\u0131lm\u0131\u015ft\u0131r (5).<\/p>\n<p>Ne yaz\u0131k ki acil servis doktorlar\u0131 aras\u0131nda palyatif ya da ya\u015fam sonu ihtiya\u00e7lar\u0131 olan hastalar\u0131n bak\u0131m\u0131nda \u00f6nemli bir kafa kar\u0131\u015f\u0131kl\u0131\u011f\u0131 ve rahats\u0131zl\u0131k oldu\u011fu bulunmu\u015ftur. Palyatif bak\u0131m s\u00f6z konusu olunca genellikle kanser hastalar\u0131 akla gelmekle birlikte acil servis hekimleri, birinin \u00f6lmesine rahatl\u0131k, onur ve sayg\u0131 ko\u015fullar\u0131nda yard\u0131m etmenin en tatmin edici klinik deneyimlerden biri oldu\u011funu belirtmi\u015fledir (6).<\/p>\n<p>Bu yaz\u0131da ya\u015fam sonu tan\u0131m\u0131n\u0131, ya\u015fam sonu beklentileri ve y\u00f6netiminden bahsederek acil servis hekimlerine bir fark\u0131ndal\u0131k kazand\u0131rmaya \u00e7al\u0131\u015faca\u011f\u0131m.<\/p>\n<p><strong>Ya\u015fam Sonu Tan\u0131m\u0131<\/strong><\/p>\n<p>Ya\u015fam sonu tan\u0131m\u0131 ara\u015ft\u0131r\u0131ld\u0131\u011f\u0131nda kar\u015f\u0131n\u0131za \u00e7o\u011funlukla palyatif bak\u0131m ile ilgili bilgiler gelmektedir. Asl\u0131nda artan ya\u015fla birlikte e\u015flik eden hastal\u0131klar\u0131n, mental ve fiziksel de\u011fi\u015fimlerin etkisi ile son y\u0131llarda pop\u00fclerlik kazanan palyatif bak\u0131m uzun erimli bir ya\u015fam sonu bak\u0131m\u0131n\u0131 tan\u0131mlayabilir. Ancak biz acil servis hekimleri i\u00e7in bu kavram\u0131 tan\u0131mlamak biraz daha g\u00fc\u00e7t\u00fcr. \u00d6ncelikli olarak ya\u015fam sonunu nas\u0131l anlar\u0131z sorusu hepimizin akl\u0131na gelen ilk soru olmaktad\u0131r.<\/p>\n<p>Ya\u015fam sonu durumlar\u0131n\u0131, yak\u0131n gelecekte insan hayat\u0131n\u0131 tehdit eden, \u015fiddetli olaylar nedeniyle sa\u011fl\u0131kta bozulma, bir hastal\u0131\u011f\u0131n geli\u015fimi olarak tan\u0131mlar (7). Bu tan\u0131m genel bir tan\u0131m olmakla birlikte ya\u015fl\u0131 hastalar i\u00e7in \u00f6zel bir tan\u0131mlama bulunmamaktad\u0131r.<\/p>\n<p><strong>Ya\u015fam Sonundaki \u0130nsanlar\u0131n Bak\u0131m\u0131ndaki \u00d6ncelikler<\/strong><\/p>\n<p>Ama\u00e7; ki\u015finin rahat\u0131n\u0131 sa\u011flamak, haysiyetini ve insanl\u0131\u011f\u0131n\u0131 \u00f6n plana \u00e7\u0131karmak olmal\u0131d\u0131r. Bu durumla ili\u015fkili \u00f6neriler sunulmu\u015ftur (1). \u015eekil 1.<\/p>\n<p><strong>1<\/strong>&#8211;<strong>Hastan\u0131n ya\u015fam sonunun de\u011ferlendirilmesi;<\/strong> ilk ad\u0131md\u0131r. Net kriterler belirlenmemi\u015f olsa da hastalar\u0131n yak\u0131n zamanda i\u015ftahs\u0131z olmalar\u0131, kilo kay\u0131plar\u0131n\u0131n h\u0131zlanmas\u0131, \u00e7evreye ilgisizlik, kendinde olamama durumu ya\u015fam sonu i\u00e7in belirti olarak de\u011ferlendirilebilir. Solunum paterni (Cheyne-Stokes solunumu), kan bas\u0131nc\u0131, cilt de\u011fi\u015fiklikleri, ajitasyon, bilin\u00e7 d\u00fczeyinde bozulmalar \u00f6l\u00fcm i\u00e7in bir belirti olsa da d\u00fczeltilebilir nedenlerle de olu\u015fabildi\u011finden kesin kan\u0131t olarak de\u011ferlendirilemez. Tecr\u00fcbeli bir doktor taraf\u0131ndan bulgular\u0131n geri d\u00f6nd\u00fcrebilir olup olmad\u0131\u011f\u0131n\u0131n de\u011ferlendirilmesi \u00f6nerilmektedir (1,8,9).<\/p>\n<p>ACEP\u2019e g\u00f6re \u0130lerleyici veya akut olarak ya\u015fam\u0131 s\u0131n\u0131rlayan bir hastal\u0131\u011f\u0131n te\u015fhisi;<\/p>\n<ul>\n<li>Hastal\u0131k seyri s\u0131ras\u0131nda kritik olaylar veya \u00f6nemli bozulma;<\/li>\n<li>Hastan\u0131n veya bak\u0131c\u0131n\u0131n ba\u015fa \u00e7\u0131kma yetene\u011finde \u00f6nemli de\u011fi\u015fiklik ve ek deste\u011fe ihtiya\u00e7 duyma;<\/li>\n<li>Hastan\u0131n \u00f6n\u00fcm\u00fczdeki 12 ay i\u00e7inde \u00f6lmesi durumunda klinisyenin \u015fa\u015f\u0131rmamas\u0131;<\/li>\n<li>\u0130lerleyici ciddi bir hastal\u0131k i\u00e7in t\u00fcm iyile\u015ftirici tedavilerin t\u00fckenmesi olarak tan\u0131mlanm\u0131\u015ft\u0131r (10).<\/li>\n<\/ul>\n<ol start=\"2\">\n<li><strong>Duyarl\u0131 ileti\u015fim kurma<\/strong>; hasta bilin\u00e7li ise kendisine bilgi verilmesi ve ailesine a\u00e7\u0131kl\u0131kla durumun anlat\u0131lmas\u0131 gerekti\u011fi vurgulanmaktad\u0131r. Bu a\u015famada hasta \/yak\u0131nlar\u0131 ya da bak\u0131m verenler prognoz hakk\u0131nda bilgi sahibi mi? Korkular\u0131 nelerdir? Planlar\u0131 nelerdir? Kendileri i\u00e7in ne yap\u0131lmas\u0131n\u0131 isterler? sorular\u0131na yan\u0131t aranabilir (1,8,9).<\/li>\n<li><strong>Kararlara dahil etmek;<\/strong> \u00e7o\u011fu ya\u015fl\u0131 tedavi s\u00fcrecini etkilerini bilmek ve karar dahil olmak ister (1,9)<\/li>\n<li><strong> Destek;<\/strong> \u00d6len ki\u015fi ve ailelerinin ki\u015fisel ihtiya\u00e7lar\u0131na sayg\u0131 g\u00f6sterilmelidir. Acil servis kalabal\u0131kl\u0131\u011f\u0131 d\u00fc\u015f\u00fcn\u00fcld\u00fc\u011f\u00fcnde mahremiyetin sa\u011flanmas\u0131 a\u00e7\u0131s\u0131ndan daha sessiz bir ortam d\u00fczenlenmelidir. Aile bak\u0131ma dahil olmak isterse desteklenmelidir. \u00d6l\u00fcm yakla\u015ft\u0131\u011f\u0131nda neler olaca\u011f\u0131n\u0131n a\u00e7\u0131klanmas\u0131 \u00f6nemlidir. Evde \u00f6l\u00fcm iste\u011fine hastan\u0131n klinik duruma g\u00f6re sayg\u0131 duyulmal\u0131d\u0131r (1,9,11).<\/li>\n<li><strong> Yeterli beslenme ve hidrasyon;<\/strong> e\u011fer ki\u015finin aspirasyon riski yoksa yak\u0131nlar\u0131 taraf\u0131ndan beslenmesine olanak sa\u011flanmal\u0131 yeterli hidrasyon verilmelidir. Oral al\u0131m sa\u011flanamayan hastalarda a\u011f\u0131z bak\u0131m\u0131 sa\u011flanmal\u0131d\u0131r (9,11).<\/li>\n<\/ol>\n<p><strong>6- K\u00fclt\u00fcrel\/Dini\/Etnik \u00d6zellikler;<\/strong> Hastan\u0131n ki\u015fisel \u00f6zelliklerine g\u00f6re yap\u0131lamas\u0131n\u0131 istedi\u011fi rit\u00fcel varsa izin verilmelidir (9).<\/p>\n<p><strong>Ya\u015fam Sonu Sorunlar <\/strong><\/p>\n<p>Anksiyete, deliryum, ajitasyon, nefes darl\u0131\u011f\u0131 ve sekresyonlar, bulant\u0131 ve kusma, a\u011fr\u0131 y\u00f6netiminden hidrasyon ve nutrisyon deste\u011fine kadar bir\u00e7ok sorun ya\u015fam sonunda g\u00f6zlenmektedir (1).<\/p>\n<p><strong>Y\u00f6netimi<\/strong><\/p>\n<p>Acil Servis hastalar\u0131nda kullan\u0131lan ABCD k\u0131saltmas\u0131 ya\u015fam sonu i\u00e7in farkl\u0131 uyarlanm\u0131\u015ft\u0131r.<\/p>\n<p>A= Bak\u0131m plan\u0131 (incelemeye uygun bir plan var m\u0131?), B= \u0130yi semptom kontrol\u00fc (dispne veya a\u011fr\u0131 gibi bunalt\u0131c\u0131 semptomlar\u0131 azaltmak i\u00e7in hemen ne yap\u0131labilir?), C= Bak\u0131c\u0131lar (mevcut bir bak\u0131m hizmeti var m\u0131?) ve D= Karar verme kapasitesi (hastan\u0131n hedefleri tart\u0131\u015fma kapasitesi var m\u0131 veya yasal vekil tan\u0131mlanm\u0131\u015f ve eri\u015filebilir mi?) (10)<\/p>\n<p>Uygun farmakolojik olmayan semptom y\u00f6netimi \u00f6nemli bir basama\u011f\u0131 olu\u015fturur. (A\u011fr\u0131y\u0131 azaltmak i\u00e7in yeniden konumland\u0131rma gibi) (9)<\/p>\n<p><strong>Kullan\u0131lan \u0130la\u00e7lar<\/strong><\/p>\n<p>Ya\u015fam\u0131n\u0131n son g\u00fcnlerinde oldu\u011funu de\u011ferlendirilen hastalar\u0131n mevcut durumlar\u0131 g\u00f6zden ge\u00e7irilmelidir. Ya\u015fl\u0131 hastalarda polifarmas\u0131 yayg\u0131nd\u0131r. Semptomlarda art\u0131\u015fa sebep olabilece\u011fi, ila\u00e7larla etkile\u015fim ihtimali, yan etkileri hasta ve yak\u0131nlar\u0131na anlat\u0131larak \u00f6nceden re\u00e7ete edilen ila\u00e7lar\u0131 durdurulur. Antihipertansif tedavi durdurulmas\u0131 \u00f6nerilen ila\u00e7lardand\u0131r. Ancak anjina ya da kalp yetmezli\u011fi ila\u00e7lar\u0131na devam edilmelidir. Hastal\u0131\u011f\u0131n \u015fiddetine g\u00f6re diyabetik ila\u00e7lar son d\u00f6nemde hipoglisemi riski de\u011ferlendirilerek durdurulabilir (12).<\/p>\n<p><strong>Oral Al\u0131m<\/strong><\/p>\n<p>Ya\u015fam sonunda oral al\u0131m\u0131n azalabilece\u011fi d\u00fc\u015f\u00fcn\u00fclerek oral olmayan yollar haz\u0131rlanmal\u0131d\u0131r. Genel olarak, en az invaziv uygulama yolu se\u00e7ilmelidir. Evde ya da bak\u0131m evinde kalanlar i\u00e7in subkutan\u00f6z yol tercih edilebilir.<\/p>\n<p>Subkutan\u00f6z, intraven\u00f6z, nazal ya da transmukozal ve rektal yollar kullan\u0131lan ila\u00e7lar\u0131n \u00f6zelliklerine g\u00f6re tercih edilebilir. (9,12)<\/p>\n<p><strong>A\u011fr\u0131<\/strong><\/p>\n<p>Opioidler a\u011fr\u0131 tedavisinin temelidir (NICE,Uptodate). K\u0131sa etkili, oral ya da sublingual opioid (2.5 mg morfin s\u00fclfat) kullan\u0131lmas\u0131 \u00f6nerilir. Semptom kontrol\u00fc i\u00e7in opioidlere ihtiya\u00e7 duyan hastalar talep edemeyebilece\u011finden, \u00f6nceden planlamas\u0131 yap\u0131lmal\u0131d\u0131r. Yayg\u0131n a\u011fr\u0131l\u0131 daha ya\u015fl\u0131 hastalarda d\u00fc\u015f\u00fck doz erken tekrar y\u00f6ntemi denenebilir. Uzun sal\u0131n\u0131ml\u0131 formlar ya\u015fam sonunda \u00f6nerilmezler. A\u011fr\u0131larda s\u0131k yineleme halinde morfin inf\u00fczyonu 30 dk da doz art\u0131r\u0131lacak ve titre edilecek \u015fekilde verilebilir. A\u011fr\u0131ya e\u015flik eden bulant\u0131 ate\u015f gibi septomlar varl\u0131\u011f\u0131onda a\u011fr\u0131 y\u00f6netiminde glukokortikoidler denenebilir. (12,13)<\/p>\n<p><strong>Dispne<\/strong><\/p>\n<p>En yayg\u0131n tedavi oksijen ve opioidleri i\u00e7erir. \u0130la\u00e7 d\u0131\u015f\u0131nda fan ile hava \u00fcflemek \u00f6zellikle kanser hastalar\u0131nda nefes darl\u0131\u011f\u0131 semptomunda azalma sa\u011flam\u0131\u015ft\u0131r. Oksijen sadece hipoksik hastalara \u00f6nerilmektedir. 2 mg sublingual morfin semptomun gerilemesinde etkilidir (12,13)<\/p>\n<p><strong>\u00a0<\/strong><\/p>\n<p><strong>Mide bulant\u0131s\u0131 <\/strong><\/p>\n<p>Genel olarak, yeni geli\u015fen mide bulant\u0131s\u0131 nadirdir ve ila\u00e7lar nedeniyle geli\u015fme ihtimali y\u00fcksektir. Opiod ili\u015fkli oldu\u011funda doz aral\u0131klar\u0131n\u0131 d\u00fczenlemek, gastroparezide metoklorpramid tedavisi \u00f6nerilebilir (9,12)<\/p>\n<p><strong>Deliryum<\/strong><\/p>\n<p>Y\u00f6netimdeki ilk ad\u0131m belirli nedenleri belirlemek ve ortadan kald\u0131rmakt\u0131r. Kullan\u0131lan ila\u00e7lar neden olabilece\u011fi gibi terminal d\u00f6nemdeki hastalarda geri d\u00f6nd\u00fcr\u00fclebilir neden bulmak her zaman m\u00fcmk\u00fcn de\u011fildir. Tedavide haloperidon 1-2 mg oral ya da subkutan ya da intraven\u00f6z \u00f6nerilir. Alternatif olarak olanzapin ve risperidon tedavide kullan\u0131labilir (12).<\/p>\n<p><strong>Solunum yolu salg\u0131lar\u0131n\u0131n art\u0131\u015f\u0131<\/strong><\/p>\n<p>\u00c7o\u011fu hasta i\u00e7in, can s\u0131k\u0131c\u0131 solunum yolu salg\u0131lar\u0131, ya\u015fam sonu s\u00fcrecin sonlar\u0131nda ortaya \u00e7\u0131kar. Hastan\u0131n yan yat\u0131r\u0131lmas\u0131, gerekli olmayan s\u0131v\u0131lar\u0131 veya enteral beslemeleri azalt\u0131lmas\u0131, sekresyonlar\u0131 hava yolundan \u00e7\u0131karmaya yard\u0131mc\u0131 olabilir. Farmakolojik tedavi etkinli\u011fine dair s\u0131n\u0131rl\u0131 kan\u0131ta olsa da glikopirolat\u00a0ve skopolamin tedaviye \u00f6nerilmektedir (9,12).<\/p>\n<p><strong>Kaynaklar<\/strong><\/p>\n<p>1- Nickel C, Bellou A, Conro S Geriatric Emergency Medicine, Dawood M Palliative and End of Life Care for the Older Person in the Emergency Department Part III, Section 26 361-369<\/p>\n<p>2- Hanson S, Brabrand M, Lassen AT, Ryg J, Nielsen DS. What Matters at the End of Life: A Qualitative Study of Older Peoples Perspectives in Southern Denmark. Gerontology and Geriatric Medicine. January 2019.<\/p>\n<p>3- Pal RY, Kuan WS, Koh Y,Venugopal Y, Ibrahim I Death among elderly patients in the emergency department: a needs assessment for end-of-life care Singapore Med J 2017; 58(3): 129-133 doi: 10.11622\/smedj.2016179<\/p>\n<p>4- Cooper E, Hutchinson A, Sheikh Z, Taylor P, Townend W, Johnson MJ. Palliative care in the emergency department: A systematic literature qualitative review and thematic synthesis. Palliative Medicine 2018;32(9):1443-1454. doi:10.1177\/02692163187839202<\/p>\n<p>5- Di Leo, S., Alquati, S., Autelitano, C. et al. Palliative care in the emergency department as seen by providers and users: a qualitative study. Scand J Trauma Resusc Emerg Med 27, 88 (2019). <a href=\"https:\/\/doi.org\/10.1186\/s13049-019-0662-y3-\">https:\/\/doi.org\/10.1186\/s13049-019-0662-y3-<\/a><\/p>\n<p>6- Smith AK, Fisher J, Schonberg MA, Pallin DJ, Block SD, Forrow L, Phillips RS, McCarthy EP. Am I doing the right thing? Provider perspectives on improving palliative care in the emergency department. Ann Emerg Med. 2009 Jul;54(1):86-93, 93.e1. doi: 10.1016\/j.annemergmed.2008.08.022.<\/p>\n<p>7- European Recommendations for End of Life Care for Adults in Departments of Emergency MedicineEuSEM. 2017 https:\/\/ eusem. org\/ wp- content\/ uploads\/ 2017\/ 10\/<\/p>\n<p>8- Dawood M End of life care in the emergency department Emergency Medicine Journal 2020;37:273-278.<\/p>\n<p>9- Managing symptoms for an adult in the last days of life NICE http:\/\/pathways.nice.org.uk\/pathways\/end-of-life-care-for-people-with-life-limiting-conditions<\/p>\n<p>10- DeSandre PL, Fairbrother H, Rosenberg M , Jesus J End-of-Life Discussions in the Emergency Department 2016 <a href=\"https:\/\/www.acepnow.com\/end-life-discussions-emergency-department\/\">https:\/\/www.acepnow.com\/end-life-discussions-emergency-department\/<\/a><\/p>\n<p>11- Leadership Alliance for the Care of Dying People. Priorities of Care for the Dying Person. 2014b https:\/\/www. nhsemployers. org\/ news\/ 2014\/ 06\/ leadership- alliance-<\/p>\n<p>12- Harman SM, Bailey A, Walling AM, Palliative care: The last hours and days of life <a href=\"https:\/\/www.uptodate.com\/contents\/palliative-care-the-last-hours-and-days-of-life?topicRef=86302&amp;source=see_link\">https:\/\/www.uptodate.com\/contents\/palliative-care-the-last-hours-and-days-of-life?topicRef=86302&amp;source=see_link<\/a><\/p>\n<p>13- Sleeman KE, Collis E. Caring for a dying patient in hospital. BMJ. 2013 Apr 17;346:f2174. doi: 10.1136\/bmj.f2174.<\/p>\n<p>\u015eekil 1.<\/p>\n<p><img fetchpriority=\"high\" decoding=\"async\" class=\"alignnone  wp-image-410\" src=\"https:\/\/tatd.org.tr\/geriatri\/wp-content\/uploads\/sites\/14\/2022\/03\/181b17e7178938789916b8cd83131f94-300x204.png\" alt=\"\" width=\"410\" height=\"279\" srcset=\"https:\/\/tatd.org.tr\/geriatri\/wp-content\/uploads\/sites\/14\/2022\/03\/181b17e7178938789916b8cd83131f94-300x204.png 300w, https:\/\/tatd.org.tr\/geriatri\/wp-content\/uploads\/sites\/14\/2022\/03\/181b17e7178938789916b8cd83131f94-768x523.png 768w, https:\/\/tatd.org.tr\/geriatri\/wp-content\/uploads\/sites\/14\/2022\/03\/181b17e7178938789916b8cd83131f94-926x630.png 926w, https:\/\/tatd.org.tr\/geriatri\/wp-content\/uploads\/sites\/14\/2022\/03\/181b17e7178938789916b8cd83131f94.png 945w\" sizes=\"(max-width: 410px) 100vw, 410px\" \/><\/p>\n","protected":false},"excerpt":{"rendered":"<p>\u2018\u0130nsanlar\u0131n nas\u0131l \u00f6ld\u00fc\u011f\u00fc, ya\u015fayanlar\u0131n an\u0131s\u0131nda kal\u0131r\u2019 Dame Cecily Saunders Ya\u015flanma \u0130le \u0130lgili Genel Bilgiler D\u00fcnyada ya\u015fam beklentisi gittik\u00e7e artmaktad\u0131r. 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