協助一位急性呼吸窘迫症候群病人撤除維生治療之重症護理經驗

Critical Nursing Experience of Forgoing Life-sustaining Treatment for a Patient with Acute Respiratory Distress Syndrome

10.6142/VGHN.202003_37(1).0007

陳怡君(Yi-Chun Chen)；黃莉綾(Li-Lin Huang)；張聿仁(Yu-Jen Chang)；陳季涵(Ji-Han Chen)

急性呼吸窘迫症候群 ； 撤除維生治療 ； 安寧護理 ； acute respiratory distress syndrome ； withdrawal of life-sustaining treatment ； hospice palliative nursing

榮總護理

37卷1期（2020 / 03 / 01）

65 - 73

繁體中文

急性呼吸窘迫症候群死亡率達35%，若病人存活可能面臨身體活動及認知功能障礙、憂慮及焦慮等身心問題，不僅影響生活品質，也會造成家庭及社會經濟負擔。本文描述一位急性呼吸窘迫症候群病人，歷經呼吸器及體外維生循環系統積極治療後，因整體病況未改善，透過醫病溝通，病人及家屬考量預後及後續照護等問題，決定撤除維生治療之重症護理經驗。護理期間自2017年1月4日至1月25日，藉由觀察、會談、身體評估及病歷查閱等方式收集資料，以Gordon十一項健康功能評估工具進行整體評估，確立主要健康問題為氣體交換障礙、家屬抉擇衝突及家屬預期性哀傷等。照護過程運用全人、全家、全程及全隊之安寧照護方式，歷經安寧共照師、醫療團隊與家屬多次會議討論後，幫助他們坦然面對疾病進展，完成撤除維生治療善終之決策。在臨終階段不僅積極協助症狀處理，促進身體舒適，也引導病人完成與家人道謝、道歉、道愛、道別的四道人生，並協助完成離世前的遺願，同時同理家屬的哀傷，給予情緒支持，達到生死兩相安的照護目標。

The mortality rate of acute respiratory distress syndrome (ARDS) is more than 35%. ARDS not only degrades the quality of life of the patient but also causes family and socioeconomic burdens. Cognitive dysfunction, anxiety, biological, and psychological problems in survival aggravate patient suffering. In this paper, a critical care experience is described in which an ARDS patient underwent active treatment with mechanical ventilation and extracorporeal membrane oxygenation. However, the overall condition of the patient did not improve. The patient and his family members considered the prognosis and follow-up care and finally decided to withdraw life-sustaining treatment through medical communication. Data during the nursing period (January 4 to January 25, 2017) were collected through observation, interviews, physical assessment, and medical record review. Gordon's 11 Functional Health Pattern Assessment was used for overall assessment to establish the main health problems, which included impaired gas exchange, decisional conflicts of families, and anticipatory family grief. The hospice palliative care was administered to the person and his family by the medical team using the aforementioned process. After several conferences, the hospice care nurse and medical team assisted the families as the disease progressed and agreed to withdraw life-sustaining treatment. In the predying stage, the medical team not only actively assisted in symptom treatment but also promoted physical comfort. The medical team guided the patient through the thanking, apologizing, loving, and bidding farewell to his family stages, and fulfilled his last wishes. The grief of the family members was accompanied by emotional support to assist the patient achieve peace.

1. 許瀚仁,李怡濃,康豑云,陳蕙茹,葉春長,洪東源,高玉玲(2015)。外科重症生命末期整合護理照護模式。源遠護理，9(3)，20-26。
   連結：
2. 葉忻瑜,黃獻樑,蔡兆勳(2016)。安寧團隊提供末期病人及家屬照護與悲傷輔導經驗。安寧療護雜誌，21(2)，218-227。
   連結：
3. Bein, T.,Weber-Carstens, S.,Apfelbacher, C.(2018).Long-term outcome after the acute respiratory distress syndrome: Different from general critical illness?.Current Opinion in Critical Care,24(1),35-40.
4. Broman, L. M.,Malfertheiner, M. V.,Montisci, A.,Pappalardo, F.(2018).Weaning from veno-venous extracorporeal membrane oxygenation: How I do it.Journal of Thoracic Disease,10(Suppl 5),S692-S697.
5. Grant, A. A.,Hart, V. J.,Lineen, E. B.,Badiye, A.,Byers, P. M.,Patel, A.,Ghodsizad, A.(2018).A Weaning Protocol for Venovenous Extracorporeal Membrane Oxygenation With a Review of the Literature.Artificial Organs,42(6),605-610.
6. Herridge, M. S.,Moss, M.,Hough, C. L.,Hopkins, R. O.,Rice, T. W.,Bienvenu, O. J.,Azoulay, E.(2016).Recovery and outcomes after the acute respiratory distress syndrome (ARDS) in patients and their family caregivers.Intensive Care Medicine,42(5),725-738.
7. Pan, C.,Liu, L.,Xie, J. F.,Qiu, H. B.(2018).Acute respi rato ry dist ress synd rome: Challenge for diagnosis and therapy.Chinese Medical Journal,131(10),1220-1224.
8. 陳美黛,陳明仁(2016)。呼吸治療師參與加護病房撤除人工呼吸器之相關議題。呼吸治療，15(1)，39-48。
9. 董志明,程馨慧,蔡新茂,黃戊田(2016)。甜柑橘精油與音樂對人體生理參數及心率變異參數之影響精油與音樂的紓壓作用。實證自然醫學，2(1)，13-26。
10. 衛生福利部統計處 (2017，5 月 1 日 )．105 年死因統計年報．取自 https://dep.mohw.gov.tw/DOS/lp-3352-113.html

1. 李宜庭(Yi-Ting Lee)(2021)。照護一位A型流感合併急性呼吸窘迫症候群脫離呼吸器之護理經驗。彰化護理。28(3)。79-90。