照顧一位末期腎臟病個案選擇安寧緩和療護之護理經驗

本文描述一位末期腎臟病個案，醫師建議計畫行血液透析，個案拒絕，想順順的不帶痛苦離世，護理過程中發現家屬對個案想行安寧療護無法認同，進而產生決策衝突，護理期間個案經歷疾病惡化、面對死亡威脅，又得不到家屬體諒，而出現失落、心靈困擾等負向情緒，因此觸發筆者動機，護理期間2021年3月3日至3月10日，筆者運用身體評估、直接觀察及訪談進行生理、心理、社會、靈性四層面評估，確立有體液容積過多、決策衝突、心靈困擾等健康問題。透過監測輸出輸入、制定飲食飲水計畫、提供舒適臥位，改善體液過多造成之不適；運用醫病共享概念介入，邀請案家一同加入討論，協助其決定治療選項；利用靈性四層面照護，協助個案達到靈性平安。最後轉入安寧病房，於3月16日安詳過世。為改善護理人員缺乏實際參與運作之醫病共享決策經驗，建議將案例融入課程進行模擬演練，使第一線護理人員具備應變能力，也建議慢性腎臟病病人於未來可能會遇到的生命末期狀況，儘早進行預立醫療照護諮商，在意識清楚下自主地選擇符合個人喜好之生命末期照護方式。

關鍵字

末期腎臟病；不施行心肺復甦術；安寧緩和療護；預立醫療照護諮商

並列摘要

This paper described the nursing experience for a case of ESRD, to whom hemodialysis was suggested, but she refused. The patient expected natural death and asked for palliative care, yet her decision was not accepted by family later when palliative care was literally practiced. An obvious conflict of decision was noted. During care, patient's clinical condition got worse to a life-threatening point, and due to family's misunderstanding, he became depressed and pessimistic, which inspired the author to put this into words. The patient was cared from March 3rd to March 10th in 2021. The author utilized skills such as direct observation, physical examination, and clinical interview to conduct "the whole person" assessment, namely bio-domain, psycho-domain, social-domain, and spiritual-domain. Accordingly, health issues including fluid overload, decision conflict, mood disorder were concerned. Monitoring fluid balance, prescribing diet plans, adjusting better sleep position, dealing with edema were done on this patient. Family was also engaged in relevant discussion based on the concept of shared decision making, who indeed helped the patient in making decision on treatment, and in turn satisfied the "four domains" of health. The patient was transferred to a hospice ward eventually, and died peacefully on March 16th. In light of lack of experience in shared decision making among nurses, adding clinical cases into training courses is suggested to make frontline medical workers more resilient; "advance care planning" done earlier in CKD patients for foreseeable terminal illness is advised, for whom the best choices of terminal care could be made consciously and freely.

並列關鍵字

ESRD ； DNR ； hospice & palliative care ； advance care planning

參考文獻

凃秀妮、胡文郁、張雯雯（2020）‧末期腎病病人之安寧緩和療護與預立醫療照護諮商‧源遠護理，14（2），18-27。https://doi.org/10.6530/YYN.202007_14(2).0003

馬瑞菊、林佩璇、蕭嘉瑩、蘇珉一、曾令君（2019）‧自主善終的臨床觀點-從病人自主權利法與ACP談起‧領導護理，20（1），16-27。https://doi.org/10.29494/LN.201903_20(1).0002

陳如意（2017）‧從共享決策SDM談落實癌症病人的善終‧腫瘤護理雜誌，17，27-37。https://doi.org/10.3966/168395442017101703003

陳思穎、陳玠伊、彭靖舒、楊淑君、方基存、周宏學、唐婉如（2018）‧醫病共享決策-以Three talk model為例‧臨床醫學月刊，81（6），342-347。https://doi.org/10.6666/ClinMed.201806_81(6).0063

鍾雨珍、陳俞琪（2020）‧心腎症候群的體液處置原則概論‧榮總護理，37（2），184-191。https://doi.org/10.6142/VGHN.202006_37(2).0009

主題瀏覽