There is increasing focus on providing high quality care for people at the end of life, irrespective of disease or cause, and in all settings. In the last ten years the use of care pathways to aid those treating patients at the end of life has become common worldwide. The use of the Liverpool Care Pathway (LCP) in the UK has been criticised. In England the LCP was the subject of an independent review, commissioned by a Health Minister. The resulting Neuberger Review acknowledged that the LCP was based on the sound ethical principles that provide the basis of good quality care for patients and families when implemented properly. It also found that the LCP often was not implemented properly, and had instead become a barrier to good care; it made over 40 recommendations, including education and training, research and development, access to specialist palliative care services, and the need to ensure care and compassion for all dying patients. In July 2013, the Department of Health released a statement that stated the use of the LCP should be "phased out over the next 6-12 months and replaced with an individual approach to end of life care for each patient".
The impact of opioids was a particular concern because of their potential influence on consciousness, appetite and thirst in people near the end of life. There was concern that impaired patient consciousness may lead to an earlier death, and that effects of opioids on appetite and thirst may result in unnecessary suffering. This rapid review, commissioned by the National Institute for Health Research, used standard Cochrane methodology to examine adverse effects of morphine, fentanyl, oxycodone, and codeine in cancer pain studies as a close approximation to possible effects in the dying patient.
To determine the impact of opioid treatment on patient consciousness, appetite and thirst in randomised controlled trials of morphine, fentanyl, oxycodone or codeine for treating cancer pain.
We assessed adverse event data reported in studies included in current Cochrane reviews of opioids for cancer pain: specifically morphine, fentanyl, oxycodone, and codeine.
We included randomised studies using multiple doses of four opioid drugs (morphine, fentanyl, oxycodone, and codeine) in cancer pain. These were taken from four existing or ongoing Cochrane reviews. Participants were adults aged 18 and over. We included only full journal publication articles.
Data collection and analysis
Two review authors independently extracted adverse event data, and examined issues of study quality. The primary outcomes sought were numbers of participants experiencing adverse events of reduced consciousness, appetite, and thirst. Secondary outcomes were possible surrogate measures of the primary outcomes: delirium, dizziness, hallucinations, mood change and somnolence relating to patient consciousness, and nausea, vomiting, constipation, diarrhoea, dyspepsia, dysphagia, anorexia, asthenia, dehydration, or dry mouth relating to appetite or thirst.
Comparative measures of harm were known to be unlikely, and we therefore calculated the proportion of participants experiencing each of the adverse events of interest with each opioid, and for all four opioid drugs combined.
We included 77 studies with 5619 randomised participants. There was potential bias in most studies, with small size being the most common; individual treatment groups had fewer than 50 participants in 60 studies. Participants were relatively young, with mean age in the studies typically between 50 and 70 years. Multiple major problems with adverse event reporting were found, including failing to report adverse events in all participants who received medication, all adverse events experienced, how adverse events were collected, and not defining adverse event terminology or whether a reporting system was used.
Direct measures of patient consciousness, patient appetite, or thirst were not apparent. For opioids used to treat cancer pain adverse event incidence rates were 25% for constipation, 23% for somnolence, 21% for nausea, 17% for dry mouth, and 13% for vomiting, anorexia, and dizziness. Asthenia, diarrhoea, insomnia, mood change, hallucinations and dehydration occurred at incidence rates of 5% and below.
We found no direct evidence that opioids affected patient consciousness, appetite or thirst when used to treat cancer pain. However, somnolence, dry mouth, and anorexia were common adverse events in people with cancer pain treated with morphine, fentanyl, oxycodone, or codeine.
We are aware that there is an important literature concerning the problems that exist with adverse event measurement, reporting, and attribution. Together with the known complications concerning concomitant medication, data collection and reporting, and nomenclature, this means that these adverse events cannot always be attributed unequivocally to the use of opioids, and so they provide only a broad picture of adverse events with opioids in cancer pain. The research agenda includes developing definitions for adverse events that have a spectrum of severity or importance, and the development of appropriate measurement tools for recording such events to aid clinical practice and clinical research.
提供病人生命末期的高生活品質，逐漸被大家所重視，不論是在疾病本身或是引起的原因，和整體的安排。最近十年來，對於末期病患的照顧途徑普遍在全世界受到重視。英國Liverpool Care Pathway（LCP）的臨床照顧途徑已遭受批評。在英格蘭Liverpool Care Pathway（LCP）是獨立項目，由衛福部長審核。Neuberger審查聲明結果表示，LCP在基礎上提供了良好的優質護理服務、為患者及家屬實施正確的道德原則。LCP的往往沒有適當的執行，反而成為造成好品質的一個障礙。超過40項建議，包括教育和培訓，研究和開發，獲得專科緩合治療服務，並需要確保關心和同情所有臨終病人。2013年7月，衛生部發布了規定，LCP的應用“在未來6-12個月應逐步淘汰，取而代之為對每一個病患以個人化的臨終護理照護”之聲明。
鴉片類藥物的使用過去被高度的關注，因為此藥物可能影響末期生命的病人其意識、食慾和口渴情況。有人擔心，患者知覺受損會導致死亡的提早，食慾和口渴的情況將受鴉片類藥物的影響，可能會導致不必要的痛苦。委託國家衛生研究院的快速的回顧，採用標準的Cochrane方法學來研究癌症疼痛時，嗎啡，fentanyl, oxycodone, 和 codeine的不良影響；這些藥物在臨終病人可能產生的影響非常接近。
對於癌症病患的疼痛，以隨機對照試驗為研究方式，其鴉片類，像是：嗎啡、fentaanyl 、oxycodone 和codeine 在意識狀態、食慾或是口渴的影響。
我們評估被報導Cochrane系統中的鴉片類藥物，發生於癌症疼痛不良事件的數據，包括：嗎啡，fentanyl, oxycodone, 和codeine。
我們採納隨機複合使用四種類型嗎啡類的藥物（morphine, fentanyl, oxycodone, and codeine）來控制癌症疼痛。這些都是從四個現有或正在進行的Cochrane回顧搜尋。參加者是年滿18歲以上的成人。我們只採納全期刊發表的文章。