如何使病人得到善終－從加護病房談起

How for a Good Death: A View Point from Intensive Care Unit

馬瑞菊(Jui-Chu Ma) ； 林佩璇(Pei-Xuan Lin) ； 蕭嘉瑩(Chia-Ying Hsiao) ； 蘇珉一(Min-I Su)

《腫瘤護理雜誌》 17卷增訂刊 (2017/10) Pp. 39-50

https://doi.org/10.3966/168395442017101703004

摘要

加護病房主要之目標在於積極拯救生命，協助病人度過急性傷害並讓病人有機會回復相當的生命品質。但若只是一味的以無效或過度醫療來延長病人生命過程，終將使病人無法善終而家屬亦背負龐大之身、心、靈煎熬及經濟壓力。故本文以文獻查證方式釐清影響加護病房病人善終之原因：一、未重視非癌重症末期病人在加護病房之善終。二、病人預立醫療指示比率偏低。三、醫療人員延遲與病人討論DNR致使死亡前仍然執行延命醫療。並提出提升加護病房生命末期照護之策略包含：一、減少不適當的加護病房入住率。二、停留加護病房期間必須不間斷的評估治療目標。三、常規性的舉辦家庭會議促進醫病共享決策。四、對於生命末期之照護必須建立團隊共識。五、加護病房設置必須更具人性化。六、家屬悲傷輔導系統之建置等。藉此專題協助醫療人員面對加護病房末期病人時有所依循，並能提供病人善終、家屬無憾之全人照護。

關鍵字

加護病房 ； 善終 ； 生命末期照護

並列摘要

The primary aim in the intensive care unit (ICU) is to rescue critically ill patients and give them a chance for better quality of life. But the blind use of unsound or excessive medical treatment to simply extend the tormenting process in life eventually makes the good death unattainable to the patient leaving the family members with burdens of physical, mental and spiritual stress. Therefore, this article uses literature review to identify factors affecting the goal of good death for patients in ICU. 1. Good death of non-cancer patients in ICU has not been given enough attention. 2. The rate of signed advance directives (Ads) is low in the ICU. 3. The delayed DNR discussion with patients cause futile end-of-life treatment. The proposed strategies to improve the end of life care at ICU include: 1. Reduction in the rate of unwarranted inpatient stay in ICU. 2. Non-intermittent patient evaluations during their stay in ICU. 3. Regular family meetings for better shared decision making. 4. Building team consensus for the end of life care. 5. Much more medical humanity in ICU facility. 6. Establishment of family grief counseling system. We hope this paper can provide medical personnel with insightful instructions when they care for the terminal patients in ICU so they can deliver a better care towards a good death.

並列關鍵字

intensive care unit ； good death ； end of life care

參考文獻

李佳欣、林佩璇、羅元均、邱怡蓉、鄭婉如、蘇珉一...馬瑞菊等(2017).加護病房護理人員撤除維生醫療改善方案,安寧療護雜誌， 22 (1)· 54-74 • [Lin, C. H.., Lin, P. X., Lo, Y. C., Chiu, Y. J., Cheng, W. J., Su, M. I., ... Ma, J. C. (2017). Project of improving withdrawal of life-sustaining treatments in ICU. Taiwan Jour- nalof Hospice Palliative Care, 22(1), 54-74. doi:10.6537/TJHPC.2017.22(1).5] doi:10.6537/ TJHPC.2017.22(1).5

馬瑞菊、林佩璇、馬瑞萍、鄭婉如、張喬茹、蕭嘉瑩、蘇珉一(2017).不施行心肺復甦術(DNR)在內科加護病房氣切病人之現況分析，安寧療護雜誌, 22(2),164-179。 [Ma, J. C., Lin, P. X., Ma, J. P., Cheng, W. J., Chang, C. J., Hsiao, C. Y., & Su, M. I. (2017). A study of do-not-resuscitate (DNR) among patients with tracheostomy in medical intensive care unit (MICU). Taiwan Journal of Hospice Palliative Care, 22(2), 164-179.] doi:10.6537/ TJHPC.2017.22(2).3

馬瑞菊、鄭婉如、林佩璇、李佳欣、涂穎慧、蘇珉一(2016).安寧緩和醫療修法後對巴拉刈中毒末期病人醫療過程之影響,安寧療護雜誌 21 (1) · 46-60 • [Ma, J. C., Cheng, W. J., Lin, P. X., Li, C. H., Tu, Y. H., & Su, M. I. (2016). Influence to paraguat intoxication ter- minal patient care after hospice palliative care regulation revision. Taiwan Journal of Hospice Palliative Care, 21(1), 46-60.] doi:10.6537/ TJHPC.2016.21(1).4

馬瑞菊、林佩璇、李佳欣、蔣如富、鄭婉如、羅元均…蘇珉一等(2016).加護病房肝硬化臨終病人簽署DNR同意書與醫療處置之經驗分析,安寧療護雜誌,21 (2),180- 195 • [Ma, J. ., Lin, P. X., Li, C. H., Chiang. J. F., Cheng, W. J., Lo, Y. C., ... Su, M. I. (2016). •.. The experience of medical treatments and DNR designation among dying patients of liver cirrhosis in ICU. Taiwan Journal of Hospice Palliative Care, 21(2), 180-195.] doi:10.6537/ TJHPC.2016.21(2).5

馬瑞菊、鄭婉如、李佳欣、林佩璇、蘇珉一 (2015).加護病房生命未期病人撤除氣管內管之經驗分析,安寧療護雜誌,20(2) 120-132 • [Ma, J. C., Cheng, W. J., Li, C. H., Lin P. X., & Su, M. I. (2015). Withdrawal of endotracheal tube for patients at end-of-life in intensive care unit. Taiwan Journal of Hospice Palliative Care, 20(2), 120-132.] doi:10.6537/ TJHPC.2015.20(2).2