生命末期之病情告知與預立照護計畫

Truth Telling and Advance Care Planning at the End of Life

胡文郁(Wen-Yu Hu) ； 楊嘉玲(Chia-Ling Yang)

《護理雜誌》 56卷1期 (2009/02) Pp. 23-28

https://doi.org/10.6224/JN.56.1.23

摘要

「尊重病人的自主權」是末期照護的核心價值之一。本文先從醫學倫理原則與安寧緩和醫療條例的法律基礎談起，再分別簡述台灣推展安寧緩和醫療照護，最常遭遇的二個重要末期醫療倫理困境－「末期病情告知(truth telling)」與「預立照護計畫(advance care planning, ACP)」。末期病情告知是一個「人性化溝通」的動態過程，其簡要四原則(ACTs)為⑴告知前的評估與準備；⑵與家屬進行溝通；⑶告知過程的方式與內容；以及⑷告知後的支持與追蹤。而臨床實務執行ACP的方式與討論重點，可歸納出五個步驟：⑴呈現並說明主題；⑵促進結構式地討論；⑶完成書面文件簽署；⑷再度審視或更新預立醫療指示；以及⑸依預立醫療指示落實於實際的臨床照護情境。最後，列舉臨床常見末期病情告知與簽署預立醫療指示(advanced directives, ADs)的迷思與挑戰，包括醫療人員或家屬的心理障礙以及溝通技巧的不足等。總之，病情告知與ACP的過程是以促進病人末期生命自決權及善終為目標，具有意義的預立照護計畫討論源自互信的醫病關係，而「良好的溝通技巧」是病情告知及預立照護計畫討論的成功關鍵，能讓病人有機會自主地選擇符合個人意願的末期醫療照顧。

關鍵字

生命末期 ； 病情告知 ； 預立照護計畫

並列摘要

One of the core values in terminal care the respect of patient 'autonomy'. This essay begins with a discussion of medical ethics principles and the Natural Death Act in Taiwan and then summarizes two medical ethical dilemmas, truth telling and advance care planning (ACP), faced in the development of hospice and palliative care in Taiwan. The terminal truth telling process incorporates the four basic principles of Assessment and preparation, Communication with family, Truth-telling process, and Support and follow up (the so-called ”ACTs”). Many experts suggest practicing ACP by abiding by the following five steps: (1) presenting and illustrating topics; (2) facilitating a structured discussion; (3) completing documents with advanced directives (ADs); (4) reviewing and updating ADs; and (5) applying ADs in clinical circumstances. Finally, the myths and challenges in truth telling and ADs include the influence of healthcare system procedures and priorities, inadequate communication skills, and the psychological barriers of medical staffs. Good communication skills are critical to truth telling and ACP. Significant discussion about ACP should help engender mutual trust between patients and the medical staffs who take the time to establish such relationships. Promoting patient autonomy by providing the opportunity of a good death is an important goal of truth telling and ACP in which patients have opportunities to choose their terminal treatment.

並列關鍵字

end of life ； truth telling ； advance care planning