心臓における緩和ケア：イタリア心臓病学会/イタリア緩和ケア学会（SIC/SICP）のコンセンサス文書

[Palliative care in the cardiac setting: a consensus document of the Italian Society of Cardiology/Italian Society of Palliative Care (SIC/SICP)].

• Raffaella Antonione
• Gianfranco Sinagra
• Matteo Moroni
• Michele Correale
• Dario Redaelli
• Domenico Scrutinio
• Eugenia Malinverni
• Savina Nodari
• Raffaele Calabrò
• Italo Penco
• Giuseppe Mercuro

抄録

緩和ケアは、生命を脅かす病気に直面している患者とその家族のQOLを向上させるアプローチとして認識されている。これは、症状やその他の精神的・社会的・精神的・経済的な問題の予防、早期発見、評価、治療によって達成される。緩和ケアは予後に左右されるものではなく、病気を改善する治療や適切な症状の緩和とともに、「同時ケア」として提供することができます。緩和ケアは、ケアの場を超えた調整に依存し、患者や介護者にオープンなコミュニケーションを提供する。最近では、難治性の進行性心不全に対して、最適かつ最大限の治療法を用いて治療を行う緩和ケアの潜在的な役割に関心が高まっている。先進国では死亡者数の約3分の1を占め、入院の一般的な原因となっている。進行性心不全患者の50％は診断後1年以内に死亡し、残りの50％は5年以内に死亡する。心不全の経過は予測できないことが多く、患者の約30～50％が突然死する。心不全患者は多くの症状に悩まされており、しばしば従来の治療法に抵抗性があり、認識が不十分で治療が不十分であることが多い。心不全は命を縮める疾患であるが、治療法や技術の進歩（左室補助装置、冠動脈血行再建術、経皮弁植え込み術、植え込み型除細動器など）により、医療従事者は進行性心不全患者の管理に役立ち、世界的な状態の改善や突然死のリスクの低減につながる。一方で、終末期に向けた心血管系電子機器の管理には、生命維持療法の中止に関する法的、倫理的、宗教的な原則を認識する必要があることも認識しておかなければならない。心不全における緩和ケア提供の障壁としては、臨床的な問題（病状の軌跡）、予後の不確実性、緩和ケアを必要とする患者の特定と専門家サービスへの紹介のタイミングの失敗だけでなく、緩和ケアの役割に関する患者、家族、衛生スタッフの誤解、組織の問題、最終的には教育と時間の問題などが挙げられる。(i)臨床的および社会心理学的問題の観点から緩和ケアの対象となる心不全患者の特定 (ii)引き金となる事象と紹介のタイミングの特定 (iii)患者が報告したアウトカム指標を含む、末期心不全における症状と生活の質の測定、評価、フォローアッ プのための適切なパフォーマンス指標／尺度の特定 (iv)治療、ケアおよび組織の必要性(iv) 進行期／末期心不全の治療、ケア、組織の戦略とモデル（「ケアマネジメント」） (v) 心不全におけるコミュニケーション、倫理、先進的なケアプランニングの分野における医療従事者の知識と教育の実施。

Palliative care is recognized as an approach that improves quality of life of patients and families facing life-threatening illnesses. This is achieved through prevention, early identification, assessment and treatment of symptoms and other psycho-social, spiritual and economic issues. Palliative care is not dependent on prognosis and can be delivered as "simultaneous care", together with disease-modifying treatments and adequate symptom relief. Palliative care relies on coordination across settings of care and offers open communication to patients and caregivers. Recently, there is increasing interest in the potential role of palliative care in refractory, advanced heart failure treated with optimal, maximized therapy.Heart failure is a chronic progressive syndrome characterized by periods of stability interrupted by acute exacerbations, usually leading to reduced functional status. It accounts for approximately one-third of deaths in industrialized countries and is a common cause of hospitalization. Fifty percent of patients with advanced heart failure die within 1 year of diagnosis and 50% of the remainder within 5 years. The trajectory of heart failure is often unpredictable and approximately 30% to 50% of patients die suddenly. Patients with heart failure suffer from numerous symptoms, often resistant to conventional treatments, frequently under-recognized and under-treated. Symptom assessment and control improve quality of life in patients with advanced heart failure; this can be managed at best by collaboration between specialistic teams.Although heart failure is a life-shortening condition, therapeutic and technological advances (such as left ventricular assist devices, coronary revascularization, percutaneous valve implantation, and implantable cardioverter defibrillators) can help healthcare professionals in the management of patients with advanced heart failure, improving global condition and reducing the risk of sudden death. On the other hand, it has to be acknowledged that management of cardiovascular implanted electronic devices towards end of life requires awareness of legal, ethical, religious principles regarding potential withdrawal of life-sustaining therapies.Adequate communication with patients regarding adverse events, end of life, benefits vs burdens of therapies and interventions, treatment preferences, and decision-making should be an issue in early stages of disease. The process of advanced care planning should be clearly documented and regularly reviewed.Barriers to the provision of palliative care in heart failure include clinical issues (disease trajectory), prognostic uncertainty, failure in identification of patients who need palliative care and timing of referral to specialist services, but also misconceptions of patients, families and sanitary staff regarding the role of palliative care, organization problems, and finally educational and time issues.This document focuses on the need of further, coordinated research and work-out on: (i) identification of heart failure patients eligible for palliative care, in terms of clinical and social-psychological issues, (ii) identification of trigger events and timing of referral; (iii) identification of adequate performance indicators/scales for measurement, assessment and follow-up of symptoms and quality of life in end-stage heart failure, including patient-reported outcome measures; (iv) treatment, care and organization strategies and models for advanced/end-stage heart failure ("care management"); and (v) implementation of knowledge and education of healthcare professionals in the fields of communication, ethics, and advanced care planning in heart failure.