重症生命末期照護之新趨勢

Current Trend of End-of-Life Care in Critical Illness

10.6320/FJM.2011.15(1).07

吳春桂(Chun-Kuei Wu)；林宏茂(Hong-Mau Lin)；林芳如(Fang-Ru Lin)；林亞陵(Ya-Ling Lin)；蔡紋苓(Wen-Lin Tsai)；廖婉伶(Wan-Lin Liao)；鄭博文(Bor-Wen Cheng)；黃勝堅(Sheng-Jean Huang)

倫理 ； 加護病房 ； 生命末期照護 ； 緩和療護 ； 溝通 ； ethics ； intensive care unit ； end-of-life ； palliative care ； communication

台灣醫學

15卷1期（2011 / 01 / 25）

37 - 47

繁體中文

加護病房生命末期照護是一個新興的綜合性的專業領域，它和其他領域一樣，需要同樣高水準知識與能力。愈來愈多的共識致力於進一步改善加護病房瀕死病人與家屬的照護品質。以病人及家屬為中心的決策成為加護病房生命末期照護的主軸。加強溝通在加護重症實務上是重要的，不僅與家屬的溝通重要，內部的溝通也重要。三個倫理原則有助於生命末期照護共識的形成：(1)維生系統的「不予」和「撤除」是相等的，(2)殺害和允許死亡是有重要區別，和(3)「雙重效應的理論」(doctrine of double effect)。一旦照護目標從「治癒」調整成「舒適」，所有加護病房治療均應嚴格的再評估；臨床醫師對於「不予」與「撤除」和增進病人的舒適的治療如止痛、鎮靜及非藥物照護應具備相當的能力。除此之外，病人死亡的告知、器官捐贈的討論、死亡之後的悲傷輔導（包括家屬及醫療團隊）也是加護病房生命末期照護重要的一環。未來，對於生命末期的研究、教育與品管的努力，將有助益於加護病房生命末期照護品質的進步。

End-of-life care (EOLC) is emerging as a comprehensive area of expertise in intensive care unit (ICU) and demands as high level of knowledge and competence as all other areas of ICU practice. Consensuses are developed to improve the quality of care in ICU for patients and their families during the dying process. Patient and family-centered care and shared decision making has became to the core ideal for managing EOLC in ICU. Improvements of communication is important in practice of ICU care. Three key ethical concepts play fundamental roles in guiding end-of-life care, including the distinctions between withholding and withdrawing treatments, between actions of killing and actions allowing to die, and between consequences that are intended vs. consequences that are merely foreseen (the doctrine of double effect). The treatments should be reevaluated, once the goal of care is shifted from ”cure” to ”comfort”. Clinicians should be competent in all aspects of this care, especially in practice of withholding and withdrawing of life-sustaining treatment and the use of sedatives, analgesics, and non-pharmacologic approaches to ease the suffering of the dying process. Other knowledge unique to EOLC includes principles for notifying families of a patient's death, compassionate approaches to discuss possibility of organ donation and bereavement programs (support both families and clinical staffs). In the future, a comprehensive agenda for improving end-of-life care in the ICU should be developed to guide researches, quality improvement efforts, and educational curricula.

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