말기 암 환자에서 임상변수를 이용한 생존 기간 예측

염창환,최윤선,홍영선,박용규,이혜리,Yeom, Chang-Hwan,Choi, Youn-Seon,Hong, Young-Seon,Park, Yong-Gyu,Lee, Hye-Ree 한국호스피스완화의료학회 2002 한국호스피스.완화의료학회지 Vol.5 No.2

목적 : 의학의 발달로 인간의 생존 기간이 길어졌지만, 암 발생율과 사망율은 오히려 증가하고 있어 그로 인해 말기 암 환자는 계속 늘어나고 있는 실정이다. 말기 암 환자를 진료하는 데 있어서 환자의 생존 기간을 예측하는 것은 중요한 문제로 만약 환자의 생존 기간을 예측할 수 있다면 남은 시간에 따라 환자, 가족, 의료진은 치료의 선택에 큰 차이를 보일 것이다. 이에 저자 등은 말기 암 환자에서 사망 위험도를 높이는 예후 인자를 알아내고 이들 예후 인자의 개수에 따른 생존 기간을 예측하여 말기 암 환자의 진료에 도움이 되고자 하였다. 방법 : 2000년 7월 1일부터 2001년 8월 31일 사이에 국민건강보험공단 일산병원 가정의학과에 말기 암으로 입원한 환자 157명을 대상으로 입원당시 환자의 임상변수 31가지를 조사하였다. 그리고 환자의 의무기록과 조사된 환자의 신상기록을 가지고 2001년 10월 31일까지의 환자의 생존 여부를 확인하였다. Kaplan-Meier 방법과 로그순위 검정(log-rank test)을 이용하여 임상변수에 따른 생존 기간에 차이가 있는지를 알아보았다. Cox의 비례위험함수 모형(Cox's proportional hazard model)을 이용하여 임상변수 중 사망 위험도를 높이는 유의한 변수를 얻은 후 이를 예후 인자로 삼고, 이것을 와이블 비례위험함수 모형(Weibull proportional hazard function model)을 이용하여 예후 인자들의 유무에 따른 생존 기간의 평균, 중앙값 제 1사분위수 그리고 제 3사분위수를 계산하여 생존기간을 예측하였다. 결과 : 말기 암 환자 157명 중 성별은 남자가 79명(50.3%), 여자가 78명(49.7%)이었고, 평균 연령은 남자가 $65.1{\pm}13.0$세, 여자는 $64.3{\pm}13.7$세였다. 암의 종류를 보면 위암이 36명(22.9%)으로 제일 많았고, 폐암이 27명(17.2%), 대장암이 20명(12.7%) 순이었다. 의식변화, 식욕부진, 저혈압, 수행능력 저하, 백혈구 증가증, 중성구 증가증, 크레아티닌 증가, 저알부민혈증, 고빌리루빈혈증, 간효소(SGPT)치 증가, 프로트롬빈 시간(PT) 연장, 활성부분 트롬보플라스틴 시간(aPTT) 연장, 저나트륨혈증, 고칼륨혈증 등을 보이는 환자는 통계학적으로 유의하게 생존 기간이 짧았다. 이중 Cox의 비례위험함수 모형을 통해 수행능력 저하, 중성구 증가증, PT 연장, aPTT 연장인 경우가 환자의 사망위험도를 높이는 유의한 예후 인자로 나왔다. 생존 기간의 중앙값은 4가지 인자가 모두 있는 경우는 3.0일, 3가지만 있는 경우는 $5.7{\sim}8.2$일, 2가지만 있는 경우는 $11.4{\sim}20.0$일, 1가지만 있는 경우는 $27.9{\sim}40.0$일, 4가지 모두 없는 경우는 77일로 나왔다. 결론 : 말기 암 환자에서 수행능력 저하, 중성구 증가증, PT 연장, aPTT 연장이 사망위험도를 높이는 예후 인자임을 알 수 있었다. 이들 4개 인자를 통해 말기 암 환자에서 생존 기간을 예측할 수 있을 것으로 사료된다. Purpose : Although the average life expectancy has increased due to advances in medicine, mortality due to cancer is on an increasing trend. Consequently, the number of terminally ill cancer patients is also on the rise. Predicting the survival period is an important issue in the treatment of terminally ill cancer patients since the choice of treatment would vary significantly by the patents, their families, and physicians according to the expected survival. Therefore, we investigated the prognostic factors for increased mortality risk in terminally ill cancer patients to help treat these patients by predicting the survival period. Methods : We investigated 31 clinical parameters in 157 terminally ill cancer patients admitted to in the Department of Family Medicine, National Health Insurance Corporation Ilsan Hospital between July 1, 2000 and August 31, 2001. We confirmed the patients' survival as of October 31, 2001 based on medical records and personal data. The survival rates and median survival times were estimated by the Kaplan-Meier method and Log-rank test was used to compare the differences between the survival rates according to each clinical parameter. Cox's proportional hazard model was used to determine the most predictive subset from the prognostic factors among many clinical parameters which affect the risk of death. We predicted the mean, median, the first quartile value and third quartile value of the expected lifetimes by Weibull proportional hazard regression model. Results : Out of 157 patients, 79 were male (50.3%). The mean age was $65.1{\pm}13.0$ years in males and was $64.3{\pm}13.7$ years in females. The most prevalent cancer was gastric cancer (36 patients, 22.9%), followed by lung cancer (27, 17.2%), and cervical cancer (20, 12.7%). The survival time decreased with to the following factors; mental change, anorexia, hypotension, poor performance status, leukocytosis, neutrophilia, elevated serum creatinine level, hypoalbuminemia, hyperbilirubinemia, elevated SGPT, prolonged prothrombin time (PT), prolonged activated partial thromboplastin time (aPTT), hyponatremia, and hyperkalemia. Among these factors, poor performance status, neutrophilia, prolonged PT and aPTT were significant prognostic factors of death risk in these patients according to the results of Cox's proportional hazard model. We predicted that the median life expectancy was 3.0 days when all of the above 4 factors were present, $5.7{\sim}8.2$ days when 3 of these 4 factors were present, $11.4{\sim}20.0$ days when 2 of the 4 were present, and $27.9{\sim}40.0$ when 1 of the 4 was present, and 77 days when none of these 4 factors were present. Conclusions : In terminally ill cancer patients, we found that the prognostic factors related to reduced survival time were poor performance status, neutrophilia, prolonged PT and prolonged am. The four prognostic factors enabled the prediction of life expectancy in terminally ill cancer patients.

Safety, Efficacy, and Patient Satisfaction with Initial Peripherally Inserted Central Catheters Compared with Usual Intravenous Access in Terminally Ill Cancer Patients: A Randomized Phase II Study

박은주,박권오,김재준,오상보,정기선,오소연,홍윤정,김진혁,장주연,전웅배 대한암학회 2021 Cancer Research and Treatment Vol.53 No.3

Purpose The purpose of this study was to investigate whether routine insertion of peripherally inserted central catheter (PICC) at admission to a hospice-palliative care (HPC) unit is acceptable in terms of safety and efficacy and whether it results in superior patient satisfaction compared to usual intravenous (IV) access.Materials and Methods Terminally ill cancer patients were randomly assigned to two arms: routine PICC access and usual IV access arm. The primary endpoint was IV maintenance success rate, defined as the rate of functional IV maintenance until the intended time (discharge, transfer, or death).Results A total of 66 terminally ill cancer patients were enrolled and randomized to study arms. Among them, 57 patients (routine PICC, 29; usual IV, 28) were analyzed. In the routine PICC arm, mean time to PICC was 0.84 days (range, 0 to 3 days), 27 patients maintained PICC with function until the intended time. In the usual IV arm, 11 patients maintained peripheral IV access until the intended time, and 15 patients underwent PICC insertion. The IV maintenance success rate in the routine PICC arm (27/29, 93.1%) was similar to that in the usual IV arm (26/28, 92.8%, p=0.958). Patient satisfaction at day 5 was better in the routine PICC arm (97%, ‘a little comfort’ or ‘much comfort’) compared with the usual IV arm (21%) (p <0.001). Conclusion Routine PICC insertion in terminally ill cancer patients was comparable in safety and efficacy and resulted in superior satisfaction compared with usual IV access. Thus, routine PICC insertion could be considered at admission to the HPC unit.

Burdens, Needs and Satisfaction of Terminal Cancer Patients and their Caregivers

Chang, Yoon-Jung,Kwon, Yong Chol,Lee, Woo Jin,Do, Young Rok,Lee, Keun Seok,Kim, Heung Tae,Park, Sook Ryun,Hong, Young Seon,Chung, Ik-Joo,Yun, Young Ho Asian Pacific Journal of Cancer Prevention 2013 Asian Pacific journal of cancer prevention Vol.14 No.1

Objectives: Terminal cancer patients and their caregivers often experience traumatic stress and need many types of assistance. In the present study we interviewed terminally ill cancer patients and caregivers to determine how much burden they experienced and to find out what factors are most important for satisfaction. Design: We constructed a questionnaire including overall care burden and needs experienced, and administered it to 659 terminal cancer patients and 659 important caregivers at 11 university hospitals and 1 national cancer center in Korea. Results: Finally, 481 terminal cancer patients and 381 caregivers completed the questionnaire. Care burden was not insubstantial in both and the caregiver group felt more burden than the patient group (P<0.001). While the patient group needed financial support most (39.0%), the caregiver group placed greatest emphasis on discussion about further treatment plans (44.8%). Stepwise multiple logistic regression analyses showed that in the patient group, patient's health status (OR, 2.03; 95%CI, 1.16-3.56) and burden (OR, 2.82; 95%CI, 1.76-4.50) influenced satisfaction about overall care, while in the caregiver group, high education level (OR, 1.84; 95%CI, 1.76-4.50), burden (OR, 2.94; 95%CI, 1.75-4.93) and good family function (OR, 1.94; 95%CI, 1.24-3.04) were important. Conclusions: Our study showed that burden was great in both terminal cancer patients and their caregivers and was perceived to be more severe by caregivers. Our study also showed that burden was the factor most predicting satisfaction about overall care in both groups.

생애 말기암환자의 조기경보지수 적용

이재우(Jae-woo Lee),김예슬(Ye-Seul Kim),김용환(Yonghwan Kim),유효선(Hyo-Sun Yoo),강희택(Hee-Taik Kang) 대한임상노인의학회 2021 대한임상노인의학회지 Vol.22 No.2

As the average life expectancy increases, there is also a growing interest in how to organize the rest of life of the elderly. As end-of-life becomes important, predicting the last few days of end-of-life in terminal cancer patients and preparing death for patients and their families could be meaningful in a super-aged society in the future. It is difficult to accurately predict the remaining life expectancy for terminal cancer patients. An early warning score (EWS) is an simple indicator aimed at detecting clinical deterioration to improve patient safety in hospitals. This was developed to quantify the abnormal levels of vital signs and patients with sudden deterioration in the early stage. EWS is closely related with short-term mortality or acute exacerbations in patients, such as intensive care unit admissions. Therefore, applying the EWS to terminal cancer patients at end-of-life time, it can be considered that it has the potential to be used as an auxiliary indicator to inform that the death of patients is impending.

연명치료중단 법제화의 전제조건에 대한 검토 -세브란스병원사건에 대한 법원 판결의 의미와 시사점-

이상용 ( Sang Yong Lee ) 한국법정책학회 2012 법과 정책연구 Vol.12 No.3

연명치료중단의 문제는 2008년 세브란스병원사건을 계기로 다시 한 번 커다란 사회적 관심의 대상이 되었는데, 이에 대한 법원의 판결에서 연명치료중단의 일정한 기준을 발견할 수 있다는 점에서 관련 논의의 의미 있는 진전을 이루게 되었다고 볼 수 있다. 그러나 일정한 경우 연명치료의 중단이 허용되어야 한다는 데에는 대체로 많은 사회구성원들이 동의하고 있지만, 그 사회적 합의의 구체적 내용에는 불분명한 점들이 여전히 존재한다. 의견이 대립하는 분야는 사전의료지시서의 요건과 효과, 연명치료중단의 대상 환자, 중단될 수 있는 연명치료의 종류 등 여러 가지가 있지만, 그것이 가장 첨예하게 드러나는 사안은 자발적 호흡을 하고 있지만 이미 장기간의 의식불명상태에 빠져있고 또 앞으로도 상당기간 그 의식불명상태가 계속될 것으로 예측되는, 회복의 가능성이 매우 희박한 지속적 식물상태 환자의 영양공급을 중단할 수 있는가라는 문제라고 생각한다. 본 논문은 법원의 판결과 그 이후의 논의의 전개과정에 대한 검토를 통해 연명치료의 중단에 대한 우리 사회의 합의의 범위를 살펴보고, 연명치료중단이 법제화가 되어야 한다면 그것은 어느 범위에서 연명치료의 중단을 허용하는 것이 되어야 할 것이며 어떤 점에 대한 논의와 합의가 필요한지를 살펴보고자 한다. 그리고 합의의 과정에서 자발적 호흡이 가능한 지속적 식물상태의 환자의 경우에도 연명치료 중단의 가능성을 열어놓고 논의를 하는 것이 필요하다고 제안한다. Owing to the remarkable advances in medical science and technology, terminally ill patients can survive longer than ever expected before. But the patients can not regain consciousness in many cases. The Supreme Court of Korea decided that if a patient is in an irreversible condition with imminent death, the discontinuation of treatment can be approved as the patient`s self-determination, in 2009. In this case, a 76-year-old patient was in a persistent vegetative state, with artificial ventilation treatment. The Court approved the request of the patient to remove the artificial ventilation treatment, and allowed the patient to die. Therefore the artificial ventilation treatment was removed, but the patient maintained spontaneous breathing for about seven months, and deceased. This decision presented the general criteria and process of withdrawal of life-sustaining management in Korea for the first time, the majority opinion of the decision ruled that in state of critically irreversible condition the patient can exercise the right to self-determination based on human dignity, value and the right to pursuit of happiness, the withdrawal can be allowed. However, the court defined the concept of ``irreversible condition`` and ``imminent death condition`` vaguely and there is enough ground for controversy. A generally accepted consensus of end-of-life care decision-making appeared in Korean medical society after that decision, and guidelines to withdrawing life-sustaining therapies were published in 2009. Still there is an opposition to the legalization of the withdrawal of life-sustaining management, the majority of people seem to assent to the withdrawal of life-sustaining management in a specific condition, but in particular there are conflicts of opinion, An advance directive is a measure to certify the determination of incompetent patients, but the persistent vegetative state is so rare and unexpected condition, and it may happened suddenly, If the patient have made out an advance directive, there are many difficulties with advance directives. And withdrawal of life-sustaining artificial nutrition and hydration is more serious and critical problem, especially in case of the persistent vegetative state patient. Therefore national consensus should be made before the legislation of the withdrawal of life-sustaining management, especially about the persistent vegetative state.

급성 호흡곤란을 호소하는 노인 중환자에서 혈청 N-Terminal Pro-Brain Natriuretic Peptide 검사의 유용성

최정은 關東大學校 醫科大學 醫科學硏究所 2004 關東醫大學術誌 Vol.8 No.1

Background N-terminal pro-Brain type natriuretic peptide (NT-proBNP) originates mainly from the ventricle and has been shown to be of diagnostic value in congestive heart failure, predictive of sudden cardiac death and prognostic for death in acute coronary syndrome. And recent studies suggested NT-proBNP can be increased in various disease such as pulmonary embolism, primary pulmonary hypertension and essential hypertension. Sometimes it is difficult to differentiate a cause of dyspnea in aged patients with variable underlying diseases. In this study, the NT-proBNP were measured from aged dyspneic patients in intensive care unit to evaluate the usefulness of NT-proBNP in differentiating the cause dyspnea and in predicting prognosis of that patients. Methods 42 aged patients with dyspnea in ICU, who were hospitalized from April to October 2003 were enrolled in this study. Elecsys proBNP with electrochemiluminescence method was used for measurement of serum NT-proBNP. The acute physiology and chronic health evaluation (APACHE) II score and mortality were recorded. Results The mean age was 76.2±6.3 years old. There were 14 males and 28 females. The mean NT-proBNP level was 8186.4±1742.2 pg/ml, which showed marked elevation compared to normal values. There were significant differences in NT-proBNP levels among the variable diseases (p=0.017). The mean APACHE Ⅱ score was 13.4±0.8 and predicted mortality was 16.9±1.8%. The correlation between the NT-proBNP and APACHE Ⅱ score, between the NT-proBNP and mortality were significant (r=0.355, p=0.021 & r=0.346, p=0.025) Conclusion The measurement of serum NT-proBNP is helpful and noninvasive tool for differentiating of various cause of dyspnea and also useful for predicting prognosis in aged patients with dyspnea.

Theological Review on Life Support Treatment

Ku, Inhoe 이화여자대학교 생명의료법연구소 2012 BIOMEDICAL LAW & ETHICS Vol.6 No.1

God speakes about life in many ways. Some remarkable statements are included in the idea of man as image of God. The first one is that life comes from God and is his gift, his image, his mark. God is the only owner of life; therefore this is an unthinkable reality, which is removed from the power of any man. Traditional analyses of death and dying acknowledge, at least implicitly, that decisions about health care take place in the context of relationships, social interdependence, and social obligations. However, bioethics through the middle of the twentieth century still concentrated attention on individual decisions and guarantees of autonomy. Christian teaching has traditionally opposed active causation of death, even for suffering, terminally ill patients. At the same time, death need not be opposed absolutely. The death of a very elderly or ill person may be accepted as appropriate, and measures to prolong life may be refused. To determine the moral character of decisions to use or refuse means, the context must be examined. For one thing, a means that is virtually useless or very dangerous in one era of medical practice may improve in efficacy as time goes on. Similarly, what is not tolerable or effective for one patient may be reasonable and useful for another. Moreover, the patient considering the acceptance of death must sometimes take into account the common good, for which he or she may still have a responsibility.

‘김할머니’ 사례로 살펴본 가정적 연명의료결정에 관한 연구 - 호스피스․완화의료 및 임종과정에 있는 환자의 연명의료결정에 관한 법률과 관련하여 -

김장한 대한의료법학회 2016 의료법학 Vol.17 No.2

Recently, the Well-dying Act was legislated in Korea, and it will come into effect in August 4, 2017. This Act allows to withdraw the life sustaining treatment from impending death patients and also provide the hospice and palliative treatment to terminal patients. In the Supreme Court’s case so called “Madam Kim”, medical condition of Madam Kim was a persistent vegetative status owing to brain damage and her family members wanted to remove the artificial ventilation. In 2009, the Supreme Court allowed to withdraw the artificial ventilation under the specific conditions. We applied this new Well-dying Act to the Madam Kim’s case hypothetically in order to know this Act can reasonably solve the problem of life sustaining treatment for dying or terminal patients. For the impending patients, the Well-dying Act has the problem not to withdraw the futile treatment due to the advance directives of patients. Vice versa, the terminal patients have no chance to withdraw the life sustaining treatment due to the this Act impose the duty to provide the hospice and palliative treatment despite of advance directives. We need to ruke out the persistent vegetative patients from the terminal patients caused by the cancer, acquired immune deficiency syndrome, chronic obstructive lung disease and chronic liver cirrhosis, In addition, we have to discuss the effect of the advance directives of terminal patients in view of self determination right. 최근에 환자연명의료결정법이 제정되었고, 2017년 8월 4일부터 효력을 발휘하게 된다. 이 법은 임종 과정 환자를 연명 의료 중단의 대상으로 하고, 말기 환자는 호스피스․완화의료를 받도록 하고 있는 것이 특징이다. 김할머니 사건은 뇌손상으로 지속적 식물 상태에 빠진 환자에 대하여 가족이 인공호흡기 제거를 요청한 사건으로, 2009년 대법원이 일정한 요건을 인정하여 인공호흡기 제거를 허용한 사건이다. 김할머니 사건에 대하여 환자연명의료결정법을 적용하였을 때, 과연 대법원과 같은 내용의 결정이 내려 질 수 있는지 가정적 적용을 시도하였다. 환자연명의료결정법은 임종과정 환자 연명의료결정에 환자의 의사내용을 요건으로 하기 때문에, 도리어 인공호흡기 제거가 불가능할 수도 있고, 과잉적 의료개입이 지속될 가능성이 있다. 반대로 말기 환자의 경우는 연명의료중단에 대하여 환자의 자기결정권을 인정하지 않기 때문에 김할머니 사건에서 인공호흡기 제거가 불가능하다고 해석할 가능성도 있다. 현재 법에는 암, 후천성면역결핍증, 만성폐쇄성호흡기 질환, 만성간경화 및 보건복지부령으로 정하는 질환을 말기 환자로 규정하고 있는데, 보건복지부 지침 등을 통하여 김할머니와 같은 지속적 식물상태를 명확하게 제외하다는 해석이 필요하고, 전체적으로는 말기 환자의 사전 연명 의료 의사에 대한 자기 결정권 인정 여부에 대하여 재논의도 필요하다.

생명 말기의 법적 안정성 : 환자의 생명 징후와 관련한 연명치료 중단의 허용 요건을 중심으로

류화신(Ryoo Hwa-Shin) 忠北大學校 法科大學 法學硏究所 2010 法學硏究 Vol.21 No.2

This study discusses legal issues surrounding the withdrawal of treatment for terminal patients. on May 21, 2009, the Supreme Court of Korea ruled that patients have the right to terminate medically meaningless treatment upon confirmation that their illness is indeed irreversible. The Supreme Court´s decision thus makes proof of the irreversibility of a patient´s condition an important process in legitimatizing a patient´s decision to terminate life-sustaining treatment. However, since medical practice rejects explanations in terms of "essences" and is affected by issues of subjectivity, I argue that physicians cannot give indisputable confirmation of the irreversibility of a patient´s terminal illness, as required by the Supreme Court´ ruling. So, this study points to a need for greater social consensus in Korea on the permissible level for the rejection of life-sustaining treatment not to damage the legal stability.

존엄사의 헌법적 보장-죽음에 대한 자기결정권의 구성요건 설정을 중심으로-

주재경 원광대학교 법학연구소 2022 圓光法學 Vol.38 No.4

South Korea recognizes death with dignity only in the form of cessation of life-sustaining treatment for patients in the process of dying. Accordingly, a terminally ill patient or a patient in a persistent vegetative state cannot make a decision to die with dignity, and even if he or she is the target, there are limitations in choosing a method of dying with dignity such as physician-assisted suicide. These limitations cannot preclude discussion from the stage of component requirements. Therefore, in the decision to die with dignity, it is necessary to ensure that death with dignity is sufficiently guaranteed through the establishment of the component requirements for the right to self-determination on death. Regarding the requirements for becoming the subject of the right to self-determination on death in the decision to die with dignity, the requirements of irreversibility and the uselessness of treatment become the focal points. Accordingly, it is against the principle of equality to exclude a patient who has no essential difference from a patient in the process of dying and who meets the requirements from the subject. Therefore, in principle, it is desirable to acknowledge the subjectivity of the right to self-determination on death for these patients. First, in terms of the right to defense of the right to self-determination on death, the subject of the decision to die with dignity can request that the state stop restrictions on physician-assisted suicide. In the same respect, it is possible to ask the state to make a decision to discontinue general life-sustaining treatment. Next, based on the social rights aspect of the right to self-determination on death, the subject of decision to die with dignity can claim the right to receive social insurance and public assistance from the state. In particular, it can be requested that the state prepare overall welfare conditions such as hospice and palliative care systems so that patients' self-determination can be free from economic pressure. And, in terms of the protective right of the right to self-determination on death, the subject of the decision to die with dignity may claim the right to receive assistance from a doctor to the state. For example, if death with dignity is carried out by a private person other than a doctor, the right to self-determination on death may be violated, so the patient can request legislation to the state that obligates the participation of doctors in the decision to die with dignity. Lastly, in terms of the procedural right of the right to self-determination on death, in relation to organizations, supplementary legislative requests can be made to the state to expand the establishment or vitalize the operation of the Medical Institution Ethics Committee or the Public Ethics Committee. Regarding the procedure, it may be possible to request the state to prepare legislation to supplement the procedure for implementing death with dignity.