癌末病人撤除氣管內管之照護經驗

Care Experience of Withdrawing Life-sustaining Treatment for a Terminally Ill Patient

10.6537/TJHPC.202107_25(3).06

詹璧華(Pi-Hua Chan)；梁惠茹(Hui-Ju Liang)；賴維淑(Wei-Shu Lai)；釋宏琳(Hung-Lin Shi)

末期病人 ； 撤除維生醫療 ； 倫理 ； terminally ill patient ； withdrawal of life-sustaining treatment ； ethics

安寧療護雜誌

25卷3期（2021 / 07 / 01）

284 - 297

繁體中文

醫療日益進步，諸多醫療措施可延長病人生命，但當醫療處置已使病人身心承受極大痛苦，此時病人有權拒絕無益的維生醫療。撤除維生醫療需考量病人自主意願，也要經過醫療團隊嚴謹的評估過程，進而擬訂與提供病人與家屬適切的撤除前中後照護計畫。本文探討一位鼻咽癌末期病人撤除氣管內管照護經驗，病人罹癌後皆在外院治療，因呼吸喘就近到本院急診求治，當下病人雖清楚表達拒絕插管意願，然而團隊尚無足夠證據判斷病人疾病已達末期，且因病人病況緊急，醫師先為病人放置氣管內管，故而引發後續撤管難題；此外，因病人與案妻不忍年邁父親與成年孩子面對撤管壓力，向團隊表達希望獨自面對撤管過程。照護期間為2020年1月9日至1月18日，藉由閱讀病歷、身體評估、會談等方式收集資料，確認病人有「頭頸部疼痛」、「呼吸困難」、「案妻獨自面對病人撤管之壓力」與「案妻預期性哀傷」等問題。團隊藉由疼痛評估，給予止痛止喘藥物、鎮靜劑及提供舒適護理，以緩解病人疼痛及呼吸困難；在個案討論會中運用倫理四面向分析與權衡撤管之利弊得失，凝聚團隊共識；透過召開家庭會議，扮演家屬間的溝通橋樑，促進家屬互動，以緩解案妻決策壓力，同時提供家屬預期性哀傷撫慰，使病人、家屬及醫療團隊三平安。希望藉此照護經驗分享，作為臨床照護參考。

Medical treatment is progressing day by day, and many medical measures can prolong the life of patients. However, when medical treatment has caused great suffering to the terminally ill patients, they have the rights to refuse futile life-sustaining treatment. Patient autonomy, rigorous evaluation, and high quality of care plans before, during, and after removal are needed when medical team offer a patient Withdrawing Life-Sustaining Treatment (WLST). This article described the nursing experience of a patient with end-stage nasopharyngeal carcinoma. After the diagnose of cancer, this patient received medical treatment at the other hospital. This time, the patient was sent to the emergency department of our hospital due to dyspnea. Because of unclear medical condition of the patient, endotracheal tube was inserted to help him breathe. The patient had expressed to the medical team the desire to remove the endotracheal tube, but his wife could not bear involvement of the aged father and the adult children and decided to face the evacuation process alone. Thus, this case was selected for in-depth discussion. The nursing period was from January 9 to January 14, 2020. During the process, data was collected by means of reading medical records, physical assessments, interviews, and companionship. A comprehensive assessment was conducted to identify the major health-related problems: head and neck pain, dyspnea, and that his wife was facing pressure and anticipatory grief caused by this medical decision. Through nursing care such as pain assessment, providing analgesics and sedatives, comfort care to relieve pain and dyspnea, guiding emotional expression of the patient's wife, serving as the bridge of communication among the patient, the wife, and the sons, and conducting case conference and family conference, the patient and his family members received good quality of care, the wife's decision-making pressure was relieved, and building consensus among family members. To keep peace among the patient, his family members and the medical team, we made the withdrawal decision in line with ethics and laws via weighing the benefits and harms given by ethical analysis, and provided anticipatory grief care. We hope that the sharing of care experience can be used as a reference for clinical care.

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