善終預約：從急診室看台灣預立醫療自主計畫之實踐

2013年5月15日安寧緩和醫療條例三度修法，公告修正安寧緩和醫療條例五款意願書，接著2015年12月18日立法院三讀通過《病人自主權利法》，民眾可在先預立「醫療決定」，且有選擇「拒絕醫療」的權利，這樣艱難卻立意良善的條例，是基於對生命做出最大利益的權衡考量與尊重。但現行安寧條例裡所發展推動的「預立醫療自主計畫（Advance Care Planning；ACP）」，針對回應每個人臨終生命理想的善終選擇真的完善了嗎? 本研究目的將深入探討兩個核心的相關問題，第一是討論生命個體的自主性如何突顯末期生命照護的議題；第二則是探討預立醫囑與生命關懷之間的異同。採取參與式研究以及病歷回溯之質性研究，本研究藉由北部某醫學中心的急診室裡，以病歷回溯方法蒐集55位面臨生死交鋒問題，啟動討論、簽署或是執行關乎DNR或預立醫囑簽署的相關事宜時所面對的社會與文化的影響。結果顯示：1.簽署預立安寧緩和醫療意願及簽署DNR的人數會隨著年齡增長而有簽署比例增加的趨勢。2.當前的急診醫療對於臨終生命的醫療處置，能夠給予的安寧緩和醫療不足也還不完善。3. 提早簽署預立安寧緩和醫療暨維生醫療抉擇意願書，能減少不必要的侵入性醫療程度，達到自己希望的臨終品質。4.一個緊密良好的家庭婚姻人際關係，會讓人更有意願及動機提早進行醫療規畫。5.當所罹患的疾病有一個明確的發展走向死亡時，個體對自身醫療情況越了解，會促使患者提早去簽署預立安寧緩和醫療既維生醫療抉擇的意願。6.簽署DNR的議題不在受限於高齡者該有的生命自決意識，而是不同的年齡階段都該有的生命自決態度。研究中強調的生命關懷是需要藉由個體的生命自決意識來達成，而現行推動的預立醫療自主計畫就是生命自決很好的實踐，進而從實踐中得以維持個體及其照顧者的生命品質，故這樣的結論希望能作為日後生命教育相關研究的延伸課題。

關鍵字

預立醫療自主計畫；生命自決；不施行心肺復甦術；急診臨終照護；生命關懷

並列摘要

The draft of 3rd revision of Taiwan’s “Hospice and Palliative Care Act” announced on May 15th, 2013, enacted the advance directive document in five a letter of intent. On December 18, 2015, the Legislative Yuan finally passed the 3rd reading of the Taiwan’s “Patient Self-Determination Act”. It allows patients to have their rights to sign a letter of intent independently, and to refuse any treatments and terminate Advanced Hospice Palliative Care and Life Sustaining Care Choices of Intent. This difficult but well-intentioned case is based on the right to the best interests and respect of life. The current Hospice and Palliative Care Act is to set into action of “Advance Care Planning （ACP）”, which give us, as a human being, a hospice chance to make decisions for facing our ending of life. Though, is it true that the current ACP program regarding has covered all aspects of people’s choices for their ending stage of life? In this research, two main topics will be further discussed. The first is to discuss patient self-determination at his/her life ending stage, and 2) to explore the differences between making a pre-medical decision and care for life. The main method that was used in this research was either to review historical medical records or to have patient participate this research directly. The statistic result presents in this research was retrieved from an Emergency Room in a Teaching and Learning centre in North Taiwan. A retrospective approach was used to the collection of historical medical records from the 55 patients who were at their life ending stage, activating the discussion, signing, or doing business related to the social and cultural influences of the DNR or the pre-medical decision. Results show: 1) the rates of signing a pre-medical decision and DNR had an increasing trend when people age up, 2) the insufficiency and incompleteness from the current medical treatment in the final life of medical treatment provided by the ER team 3) unnecessary invasive medical care could be reduced if a pre-medical decision is signed at earlier stage, which could have the quality of life the patient pictures during their final stage, 4) a well-established relationship between family, spouse, and friends would increase willingness and motivation for arranging medical planning, and 5) when a disease has a clear development to death, the more you know about your own medical situation, the more likely it is that the patient will sign a pre-medical decision. 6) The issue of DNR is not to be limited to the life-conscious of the senior citizens, but to the life-self-determination of all different ages. The emphasis of care for life in this study is to be achieved through the life of the individual. The current pre-medical decision program is a good practice for the life-self-determination, and further to be able to maintain the life quality of the individual. This conclusion is expected to be an extension of the study of Life education in the days to follow.