ส่วนที่ 1 ข้อมูลเอกสาร
| ชื่อ CNPG | การพยาบาลผู้ป่วยระยะท้ายและการดูแลแบบประคับประคอง (Palliative Care) |
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| วัตถุประสงค์ | บรรเทาอาการทรมาน ดูแลกาย-ใจ-จิตวิญญาณ ผู้ป่วยและครอบครัว |
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| มาตรฐานอ้างอิง | WHO Palliative Care Definition, NCP Clinical Practice Guidelines, IAHPC, กรมการแพทย์ |
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1.1 Palliative Care Principles
- Whole-person care: physical, psychological, social, spiritual
- Patient + family as unit of care
- Start early, parallel with curative treatment
- Interdisciplinary team approach
- Not equal to "giving up"
- Extends to bereavement
ส่วนที่ 2 Symptom Assessment
2.1 ESAS (Edmonton Symptom Assessment Scale)
Rate 0-10 for 9 symptoms:
- Pain, Tiredness, Nausea, Depression, Anxiety
- Drowsiness, Appetite, Well-being, Shortness of breath
- Goal: < 3 for all symptoms when possible
2.2 Pain Assessment
- PQRST: Provocation, Quality, Region/radiation, Severity, Timing
- Nociceptive (somatic/visceral) vs Neuropathic
- NRS 0-10, FLACC (non-verbal), FACES (children)
- Total pain concept: physical + emotional + social + spiritual
ส่วนที่ 3 Pain Management (WHO Analgesic Ladder)
3.1 Step 1: Mild Pain (NRS 1-3)
- Acetaminophen 1 g q 6h (max 4 g/day, 3 g if elderly/liver)
- NSAIDs (Ibuprofen 400-800 mg q 6-8h) — caution renal/GI
- ± adjuvants
3.2 Step 2-3: Moderate-Severe Pain (NRS ≥ 4)
| Opioid | Starting Dose (Oral) | Equianalgesic IV |
|---|
| Morphine | 5-15 mg q 4h | 3:1 (30 mg PO = 10 mg IV) |
| Oxycodone | 5-10 mg q 4-6h | 2:1 (20 mg PO = ~10 mg IV) |
| Hydromorphone | 2-4 mg q 4h | 5:1 (hydromorphone more potent) |
| Fentanyl patch | 25 mcg/hr (stable pain) | 100:1 vs morphine IV |
| Methadone | Complex conversion — specialist only | - |
3.2.1 Breakthrough Pain
- Rescue dose: 10-15% of total daily dose, q 1-2 hr PRN
- If > 3 rescues/day → increase baseline by 25-50%
- Convert 50% IV/SC to oral when stable
3.3 Opioid Side Effect Management
| Side Effect | Management |
|---|
| Constipation (always) | Start stimulant laxative (senna) + stool softener with every opioid prescription; bisacodyl, lactulose, methylnaltrexone |
| Nausea (1-2 weeks) | Metoclopramide, Haloperidol 0.5-1 mg |
| Sedation (3-5 days) | Usually resolves; consider methylphenidate if persistent |
| Respiratory depression | Naloxone 0.04-0.2 mg IV (dilute), titrate slowly |
| Myoclonus | Opioid rotation, hydration |
| Pruritus | Antihistamine, opioid rotation |
| Delirium | Haloperidol, opioid rotation |
3.4 Adjuvant Analgesics
- Neuropathic pain: Gabapentin, Pregabalin, Duloxetine, Amitriptyline
- Bone pain: NSAIDs, bisphosphonates, radiation
- Visceral pain: Anticholinergics (hyoscine)
- Inflammation: Dexamethasone 4-8 mg/day
ส่วนที่ 4 Non-Pain Symptoms
4.1 Dyspnea
- Opioid: Morphine 2.5-5 mg PO q 4h (or 1-2 mg IV/SC) — first-line
- Oxygen (if hypoxic, SpO₂ < 90%)
- Fan to face
- Position: upright, prone
- Anxiolytic: Lorazepam 0.5-1 mg if anxiety component
- Treat reversible causes: effusion (thoracentesis), anemia
4.2 Nausea & Vomiting
- Identify cause: obstruction, medication, ICP, metabolic
- Metoclopramide 10 mg q 6h (prokinetic, gastroparesis)
- Haloperidol 0.5-2 mg (chemical trigger zone)
- Ondansetron (chemo, radiation)
- Dexamethasone (ICP, inflammation)
- Hyoscine (bowel obstruction)
4.3 Constipation
- Stimulant + softener prophylactically
- Senna + docusate 2 tabs BID
- Bisacodyl 10 mg PO/PR
- Lactulose 30 ml BID
- Methylnaltrexone for opioid-induced (SC)
- Rule out impaction (rectal exam)
4.4 Delirium
- Reversible: medications, pain, UTI, hypercalcemia, opioid toxicity
- Haloperidol 0.5-2 mg q 4h PRN (first-line)
- Non-pharmacological: orient, reduce stimuli, family presence
- Severe agitation: chlorpromazine, midazolam (palliative sedation)
4.5 Terminal Secretions ("Death Rattle")
- Position: side-lying
- Reduce fluids
- Hyoscine hydrobromide 0.4 mg SC q 4h
- Glycopyrrolate 0.2 mg SC q 4-6h
- Gentle suctioning only if needed
- ⚠️ Family education: sound distressing but patient usually not distressed
4.6 Fatigue
- Rule out treatable: anemia, depression, hypothyroid, sleep disturbance
- Energy conservation, pacing
- Methylphenidate 5-10 mg in morning (selected patients)
- Corticosteroid short-term
ส่วนที่ 5 End-of-Life Care (Last Days)
5.1 Signs of Imminent Death (Days to Hours)
- Decreasing oral intake, difficulty swallowing
- Sleeping most of time, withdrawn
- Cool/mottled extremities
- Cheyne-Stokes breathing
- Incontinence
- Terminal secretions
- Restlessness or calm
5.2 Comfort Care Plan
- Discontinue: non-essential labs, V/S, medications, IV fluids
- Continue/start: opioid, antiemetic, anti-secretory, anxiolytic
- SC route if unable to swallow
- Mouth care q 2 hr (swab, lip balm)
- Position change q 2-4 hr for comfort
- Minimize disruption
5.3 Spiritual & Cultural Care
- Religious preferences (Buddhist monks, priest, imam)
- Traditional practices
- Family gathering, rituals
- Cultural preferences around body after death
ส่วนที่ 6 Family Support
6.1 Communication
- Family meeting: goals of care, expectations
- SPIKES protocol for bad news
- Ask-Tell-Ask
- Honest but hopeful
6.2 Advance Care Planning
- Living will / Advance directive
- Power of Attorney for healthcare
- DNR orders (ภายใต้ พ.ร.บ. สุขภาพ มาตรา 12)
- Preferred place of death
- Organ/tissue donation wishes
6.3 Bereavement
- Anticipatory grief support
- Post-death follow-up call
- Bereavement cards, memorial
- Complicated grief screening
- Referral to grief counseling
ส่วนที่ 7 Nursing Self-Care
- Self-awareness of emotional response
- Team debriefing after deaths
- Boundaries, work-life balance
- Compassion fatigue recognition
- Peer support
- Reflective practice
KPIs
| KPI | Target |
|---|
| ESAS assessment at admission | 100% |
| Pain score < 3 in 48 hr | ≥ 75% |
| Advance care planning discussion documented | ≥ 80% |
| Family satisfaction | ≥ 85% |
| Death in preferred location | ≥ 70% |
| Bereavement follow-up within 2 weeks | 100% |
References
- WHO. (2020). Palliative care. WHO Fact sheets.
- National Consensus Project. (2018). Clinical Practice Guidelines for Quality Palliative Care, 4th Edition.
- International Association for Hospice & Palliative Care (IAHPC). Essential Medicines List.
- กรมการแพทย์. แนวทางการดูแลรักษาแบบประคับประคอง.
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