運用安寧療護於重症病房中照顧肺癌末期病人之經驗

Hospice Care Experience of Caring a Terminal Lung Cancer Patient in Intensive Care Ward

10.6386/CGN.201812_29(4).0013

藍雅渝(Ya-Yu Lan)；林玉菁(Yu-Ching Lin)；林晶晶(Ching-Ching Lin)

非小細胞肺癌 ； 安寧療護 ； 重症病房 ； non-small cell lung cancer ； hospice care ； intensive care ward

長庚護理

29卷4期（2018 / 12 / 01）

647 - 656

繁體中文

肺癌為高致死率的癌症，對個人、家庭都會造成很大的影響及傷害，即使在重症加護單位，也希望病人在生命最後階段沒有痛苦，有尊嚴的走完生命旅程。本文闡述一位72歲女性，罹患非小細胞肺癌末期T4N2M1的病人，入住重症加護單位時，向醫護人員表達想要善終的願望，但其子女傾向積極治療態度不同，故護理期間105/11/28~12/4，藉由觀察、會談、身體評估及病歷查詢等方式收集資料，以生理、心理、社會及靈性四層面做評估後，確認個案有低效性呼吸型態、營養不均衡：少於身體需要及哀傷三項護理問題，護理過程運用安寧療護的「四全」概念，主動提供個別性、連續性之措施，藉由症狀控制、舒適護理緩解癌末造成的呼吸困難不適及觀察消化情況並主動與團隊討論做飲食調整，維持基本代謝需求；另召開家庭會議與家屬溝通，使其瞭解持續的無效醫療僅是殘酷地拖延死亡過程，在取得團隊及家屬的共識後引導互相道愛、道謝、道歉及道別，瞭解生命的本質及意義，進而減緩哀傷情緒。建議安排安寧療護課程訓練，在癌末病人有限的期間能夠活用協談技巧深入了解其心靈問題並輔導，達到安寧療護的初衷：病人、家屬、醫療團隊平安。期望此照護經驗分享同儕，作為日後照護此類病人之參考。

Lung cancer is highly fatal, it can cause severe impacts and damages to an individual and family. However, the intensive care units expect the patient to walk through the final stages of life without enduring pain and with respect. This report described the nursing experience of caring a 72-year-old lung cancer patient suffering T4N2M1, a non-small cell lung cancer. The patient had acknowledged that he wished a ＂good death＂ when being admitted to the intensive care ward, even though his children leaned toward active treatments. During the care-giving period between November 28 and December 4, 2016, data were collected by means of observation, interview, physical assessment, and patient histories evaluated from physical, psychological, social, and spiritual aspects. The identified nursing problems included ineffective breathing pattern, imbalance of nutrients: nutrients provided is less than body requires, and grief. We adopted four whole hospice care concept in the nursing process and actively provided individualized and continuous interventions. We controlled the symptoms and provided comfort nursing to alleviate breathing difficulty caused by terminal cancer. We observed patient's digestive condition and made dietary adjustments after team discussion to maintain his basic metabolic requirements. We held meetings with family members to further elaborate that ineffective treatments can cruelly prolong the dying process. At the end, family members reached consensus and were able to express love, gratitude, apology, and farewell to the patient and recognize the essence and meaning of life which further relieve their grief reaction. Given the limited amount of time for caring a terminal cancer patient, it is recommended that training courses on hospice care should include counseling skills to identify the spiritual problems and provide appropriate consultation that meet the goals of hospice care: a peace in mind for patients, family members, and the medical team.

1. 陳月蓉、王雅芳、郭淑華、楊婉萍(2015)。心慟不捨中放手祝福：一位末期肺癌病人之家屬預期性哀傷撫慰。安寧療護雜誌，20(1)，97-87。
   連結：
2. American Cancer Society (2016, May 16). What is non-small cell lung cancer?. Retrieved Dec 29, 2016, from http://www.cancer.org/cancer/lungcancer-non-smallcell/detailedguide/nonsmall-cell-lung-cancer-what-is-non-small-celllung-cancer
3. Maeda, T.,Hayakawa, T.(2016).Combined Effect of Opioids and Corticosteroids for Alleviating Dyspnea in Terminal Cancer Patients: A Retrospective Review.Journal of Pain& Palliative Care Pharmacotherapy,30(2),106-110.
4. 李思蓉、陳璟賢、楊妹鳳、張基晟(2012)。探討營養介入對癌症患者營養狀況與持續接受抗癌治療影響之相關性。臺灣營養學會雜誌，37(2)，51-65。
5. 李貞慧、林宜芬、金惠民(2015)。癌末病人安寧療護之營養照護。北市醫學雜誌，12(4)，27-34。
6. 林玫君、周蘭娣、蕭秀鳳(2016)。間接卡路里測定儀應用於重症病人的營養評估。呼吸治療，15(2)，65-74。
7. 黃馨葆、陳皇吉、蔡佩渝、謝雅琪、林楷煌、蔡兆勳(2014)。如何以家庭會議協助重症病人生命末期決策。安寧療護雜誌，19(3)，268-281。
8. 趙可式(2016)。安寧療護的倫理與法律。澄清醫護管理雜誌，12(4)，4-9。
9. 衛生福利部統計處（2017，6 月19 日）‧105年主要死因統計結果分析‧ 取自https://www.mohw.gov.tw/dl-33686-f713f1fb-bd64-4c0d-a810-cefabef4cb2e.html[Ministry of Health and Welfare. (2017, June 19). Taiwan's Leading Causes of Death in 2016. Retrieved from https://www.mohw.gov.tw/dl-33686-f713f1fb-bd64-4c0d-a810-cefabef4cb2e.html]
10. 鄭如芬、林雅卿、黃百后、韋至信、孫嘉玲(2014)。癌症末期病人靈性照護模式。護理雜誌，61(6)，93-97。
11. 釋普安、蔡昌雄、程裕藍、游碧真(2013)。癌末病童之靈性照顧─以安寧病房為例。安寧療護雜誌，18(1)，62-75。

1. 謝佩珊(2023)。陪妳去看澎湖的海：運用生命回顧於肺癌末期個案之照護經驗。志為護理-慈濟護理雜誌，22(3)，107-117。