末期病人NIPPV撤除及Benzodiazepine使用的臨床經驗

The Experience in Withdrawing NIPPV and Using Benzodiazepine in Care of Terminal Patient

10.6537/TJHPC.2014.19(3).5

曾子桂(Tzyy-Guey Tseng)；陳虹錚(Hung-Cheng Chen)；黃志中(Joh-Jong Huang)；黃洽鑽(Chia-Tsuan Huang)；吳建誼(Chien-Yi Wu)

安寧療護 ； 末期肺疾病 ； 末期癌症病人 ； 非侵入性正壓呼吸器 ； 苯二氮泮類安眠鎮靜劑 ； palliative care ； chronic lung disease ； terminal cancer ； non-invasive positive pressure ventilation /NIPPV ； Benzodiazepine/BZD

安寧療護雜誌

19卷3期（2014 / 11 / 01）

282 - 295

繁體中文

本文個案是位因慢性肺病使用居家型夜間非侵入性正壓呼吸器（non-invasivepositive pressure ventilation/NIPPV）的癌症末期病人。因癌症併骨頭及肺轉移，病人臥床且需他人完全照顧，生活品質不斷惡化。雖有NIPPV，仍反覆因肺炎住院。病人病況加劇，經安寧團隊與家屬詳細討論利弊後，病人及家屬皆認為NIPPV無法增加病人末期生活品質，故撤除NIPPV。然病人於撤除NIPPV當晚，為症狀控制，施打Lorazepam（Benzodiazepine/BZD）1mg 6小時後去世。不免讓醫療團隊對「末期病人移除NIPPV後使用BZD」產生疑慮及省思。目前研究，無強烈證據顯示使用NIPPV及BZD會影響末期病人存活。在安寧療護，使用BZD會產生雙果效應此一學說（the doctrine of doubleeffect）的倫理討論，只要確實告知病人及家屬治療可能帶來的優缺點並達成治療共識，在遵守台灣法律下，實行撤除NIPPV或使用BZD，符合醫學倫理並為合宜的醫療處置。

This article is about a terminal cancer patient with chronic lung disease applying domiciliary nocturnal non-invasive positive pressure ventilation (NIPPV). Because of cancer with bone and lung metastasis, he was bedridden and needed total care, with continuous deterioration of the quality of life. In spite of NIPPV there was repeated hospital admission for pneumonia. The patient's condition became progression. After full communication among hospice medical staffs, patient and family members, the patient and families did not consider that NIPPV would improve his quality of life, therefore the NIPPV was withdrawn. At that night, the patient died six hours after the injection of 1 mg Lorazepam (one kind of benzodiazepine, BZD) for symptoms relief. For this reason, the medical staffs had doubt about ＂using BZD after withdrawal of NIPPV in the terminal patient＂ and reflections. There is no strong evidence showing that using NIPPV or BZD affects the survival rate of terminal patients. Under hospice care, applying BZD may lead to medical ethics of the doctrine of double effect; however, under the conditions of informing the patient and families of the benefit and harm of the therapy, reaching consensus and complying the law of Taiwan, withdrawal of life support or applying BZD will conform to the ethics of the medical profession, and which may be the appropriate medical treatment.