協助撤除腦瘤末期個案維生醫療之護理經驗

Nursing Experience about the Withdrawal of Life-Sustaining Treatments

10.6537/TJHPC.2015.20(1).5

陳怡鈞(Chun Chen)；高秀娥(Hsiu-O Kao)；黃貴薰(Guey-Shiun Huang)

腦瘤末期 ； 安寧緩和醫療 ； 撤除維生醫療 ； end-stage of brain tumor ； palliative care ； withdrawing life-supporting treatments

安寧療護雜誌

20卷1期（2015 / 03 / 01）

54 - 66

繁體中文

本文係照護一位腦瘤末期個案，因腦出血導致到院前心跳停止，經急救後恢復自發性循環，家屬深知個案已簽署「預立選擇安寧緩和醫療意願書」，但又希望個案獲得延命治療，而面臨兩難情境之護理經驗。我們藉由直接照護、身體評估、與家屬會談及觀察其互動行為等方式收集資料，依個案生理、心理、社會、靈性等層面進行整體性評估，發現個案具呼吸道清除功能失效、照顧者角色緊張、家屬意見衝突及預期性哀傷等護理問題。我們除了提供個案復甦後照護並運用安寧療護理念，透過和家屬會談得知個案之意願；然而因個案突然發生心跳停止，家屬割捨不了個案選擇安寧緩和醫療，需面對撤除維生醫療而引發衝突與矛盾，故我們不但鼓勵家屬與個案觸摸互動，抒發其內心情感並陪伴家屬渡過哀傷與彼此意見相左的階段，進而尊重不可治癒末期個案之自主權。最後個案在家屬和醫療團隊陪伴下，安詳有尊嚴地走完生命的最後一程。

The aim of this article was to describe the experiences derived from the care plan delivered to a patient who was at the end-stage of brain tumor and was sent to the hospital due to the OHCA (out-hospital cardiac arrest) caused by the intracranial hemorrhage. After the first aid was provided, her ROSC (return of spontaneous circulation) was recovered. The patient's family members knew that she had signed the letter of intent regarding pre-determined choices for HPC (hospice palliative care) and still wanted her to acquire those active treatments. Therefore, they had to face the dilemma between the patient's will and their wish for prolonging the patient's life. The author collected data through direct care, physical assessments, meeting with the family members, observing their interactive behaviors with each other and completely evaluated the patient's conditions through 4 dimensions (physical, psychological, social and spiritual). The author had found that there were four nursing problems disturbing the patient and her family members. To the patient, the major problem was ineffective airway clearance; to her family members, problems disturbing them were caregivers' role strain, conflicting opinions of family members and the anticipatory grief among those family members. Besides providing care after ROSC, the author applied the ideas of palliative care to understand the patient's will through meeting with her family members; at that time, the signed letter of intent wasn't sent to the Bureau of National Health Insurance to be noted on her National Health Insurance certificate (also called ＂NHI card＂). However, due to the sudden cardiac arrest of the patient, confrontations and contradictions caused by the scenario that the patient had chosen to accept palliative care and those life-sustaining treatments had to be withdrawn while her family members still wanted to prolong her life. Therefore, the author tried to encourage them to touch the patient and to interact with her, to help them to express their inner feelings and to accompany the patient's family members through the grief, and then hoped that they would respect the incurable patient's right of autonomy. At last, accompanied by her family members and medical team members, the patient's mechanical ventilator was withdrawn and she peacefully finished her last journey of her life with dignity.

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