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말기섬망의 실제적 지침

Practical Guide to Terminal Delirium

전진숙
대한생물치료정신의학회 (Korean Society Of Biological Therapies In Psychiatry)|2010.12|생물치료정신의학 (Journal of the Korean Society of Biological Therapies in Psychiatry)|제16권 제2호|pp. 93-101

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참고문헌

키워드

완화의료·말기섬망·사망률·복합적 원인·복합적 중재.
주제분류정신과학

초록

섬망은 완화의료(palliative care)를 받는 환자에서 두－ 9 9 －번째로 많이 나타나는 정신과적 문제이나. 그동안 정신과의사들은 임종을 앞두고 있는 말기 환자의 치료에 그다지 관여하지도 않았고, 관심도 갖지 않았다. 본 연구는 말기 환자의 치료에 정신과의사가 개입할 필요가 있으며, 이에 대한 교육이 선행되어야 한다는 점을 환기시키 위해서 시행되었으며, 인터넷 검색으로 문헌을 수집하고 정리하여 다음의 결과를 얻었다. 1) 완화의료를 받는 환자의 20~70%에서 섬망이 나타나며, 임종 48시간 내에는 거의 대부분(90~95%)에서 경험한다. 2) 말기섬망은 환자에게 정서적 고통을 가져오고, 낯선 행동에 가족과 간병인의 부담을 가중시키며, 의사소통의 장애와 치료의 비협조는 결국 사망률을 촉진시키고, 임종시 의미있는 작별의 교환을 저해한다. 3) 섬망의 핵심증상은 의식장애, 다른 인지기능 장애,급격한 발병과 증상의 변동, 수면-각성 주기의 변화이다. 행동적 측면에서 hypoactive, hyperactive, mixed 유형으로 분류할 수 있다. 4) 섬망의 병태생리는 소인과 유발요인이 복합적으로 작용해서 발생한다. 말기섬망의 위험인자는 치매, 고령, 탈수, 뇌종양, 신부전, 영양결핍, 약물과 알코올 사용, 최근 아편이나 항우울제 사용, 통증 조절의 부족,죄책감 또는 후회 등이다. 5) 말기섬망의 치료는 예리한 평가, 원인의 규명과 복구, 약물학적, 환경적, 영적 중재의 병용으로 구성된다. 결론적으로, 생의 마지막에 거의 대부분의 환자에서겪게 되는 말기섬망은 환자 뿐만 아니라 가족 및 사랑하는 이들과 간병인들 에게도 힘든 경험이다. 말기섬망의 원인은 여러 요인이 복합적으로 작용해서 나타난다. 치료에 있어서도 약물학적 중재와 환경적 및 영적 중재를 병용하는 것이 바람직하다.

Abstract

Objectives：Delirium is the second most frequent psychiatric problems experienced in patients who are in palliative care. However, psychiatrists have not involved and have paid no attention to the care of terminal patients who are impending to death till now. The purpose of this study is to insist the importance of psychiatrists’ devotion to the care of terminal patients, in which professional training should be preceded. Methods：The English articles and e-news documents published from 1990 through 2010 are reviewed, which are obtained by internet search with words combination of terminal delirium, palliative care, end-of-life care and well-dying. Results：1) Frequency：Delirium develops in 20% to 70% of patients who are in palliative care. Almost 90% to 95%of patients experience delirium within 48 hrs of near death. 2) Implications：Terminal delirium causes emotional suffering to the patients. The unusual behavior adds burden toward the family members and caregivers. Ultimately, the communication difficulty and uncooperation to treatment facilitates mortality as well as impairs meaningful exchange of good-bye at time of impending death. 3) Symptoms：The four hallmark symptoms of delirium are impairment of consciousness, other cognitive impairment, acute onset and symptom fluctuation and sleep-wake cycle change. In behavioral view, delirium can be classified into hypoactive, hyperactive and mixed patterns. 4) Etiologies：Delirium pathophysiology may develop by combined action of predisposing(vulnerability) factors and incident factors. 5) Management：The management of terminal delirium consists of keen assessment, identification and reverse of causes, and combination of pharmacological, environmental and spiritual interventions. Conclusion：Terminal delirium occurred in almost all patients at the end of life is difficult experience toward patients as well as family, beloved and caregivers. Terminal delirium develops by the combined action of multifatorial etiologies. In treatment, multidisciplinary care combined with pharmacological, environmental and spiritual interventions is desirable.

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