A review of the application progress of pain management in hospice care
疼痛管理在安宁疗护中的应用进展综述

摘要

疼痛是终末期肿瘤患者最突出、最具侵袭性的症状之一，对身心均造成严重损伤。本文系统梳理安宁疗护中疼痛管理的理论根基、国际指南共识、国内实证证据及实践困境。以WHO三阶梯原则为药理基础、以“全人-全队-全家-全程”为照护逻辑、以生物-心理-社会-灵性（BPSS）模型为评估框架的整合性疼痛管理模式已成全球共识；国外指南在方法学质量[临床指南研究与评估系统Ⅱ（AGREE Ⅱ）标准化得分66.67%～90.28%]、多维评估工具选用[简明疼痛评估量表（BPI）、数字疼痛评分法（NRS）、行为疼痛量表（BPS）]、阿片类药物个体化滴定及文化适配性干预等方面展现较高成熟度。国内近六年临床研究（6项RCT，样本量62～104例）一致证实：规范化疼痛管理联合安宁疗护可显著降低NRS/视觉模拟评分法（VAS）/疼痛分级指数（PRI）等疼痛评分（P＜0.05），同步改善焦虑（SAS/HAMA）、抑郁（SDS/HAMD）水平及多维生活质量（FACT-G、SF-36、EORTC QLQ-C30、Barthel指数），并提升治疗依从率（最高96.15%）与护理满意度（95.00%）。然而，随机化不充分、共病混杂未校正、随访偏短（最短仅2周）、灵性需求回应碎片化、家庭角色缺位及基层动态评估失范等问题普遍存在，即“指南很丰满，落地很骨感”，高质量证据向临床转化存在结构性断层。未来亟需构建兼具文化敏感性、家庭嵌入性与灵性响应力的本土化路径，并推动社区与居家场景的标准化延伸。

Abstract

Pain is one of the most prominent and debilitating symptoms in patients with terminal cancer, causing severe psychological and physical harm. This article reviews the theoretical foundations, international guidelines, domestic evidence, and practical challenges of pain management in palliative care. An integrated model based on the WHO three-step ladder, “whole person-team-family-journey” care philosophy, and bio-psycho-social-spiritual (BPSS) assessment framework has become global consensus. International guidelines show high methodological quality [Appraisal of Guidelines for Research & Evaluation Ⅱ (AGREE Ⅱ) scores 66.67%-90.28%] multidimensional tools [Brief Pain Inventory (BPI), Numeric Rating Scale (NRS), Behavioral Pain Scale (BPS)], individualized opioid titration, and culturally adapted interventions. Chinese clinical studies over six years (6 RCTs, n=62-104) confirm that standardized pain management combined with palliative care significantly reduces pain scores NRS/Visual Analogue Scale (VAS)/Pain Rating Index (PRI)(P<0.05), improves anxiety (SAS/HAMA) and depression (SDS/HAMD), enhances multidimensional quality of life (FACT-G, SF-36, EORTC QLQ-C30, Barthel Index), and increases treatment adherence (up to 96.15%) and satisfaction (95.00%). However, methodological limitations---inadequate randomization, uncorrected comorbidity confounding, short follow-up (as short as 2 weeks), fragmented spiritual responses, absent family involvement, and irregular dynamic assessments---highlight structural gaps in evidence translation. Localized pathways integrating cultural sensitivity, family involvement, and spiritual responsiveness are urgently needed, with standardized extension to community and home settings.