為善終而做撤除維生系統之經驗分析

Withdrawal of Life Sustaining Treatment for a Peaceful Death

陳淑廷(Shun-Ting Chen) ； 沈秀宜(Hsiu-Yi Shen) ； 黃淑芬(Shu-Fen Huang) ； 李雪芬(Xue-Fen Lin) ； 林素妃(Suh-Fei Lin) ； 林秋蘭(Qiu-Lan Lin) ； 李志清(Chih-Ching Lee) ； 蕭勝煌(Sheng-Huang Hsiao)

《北市醫學雜誌》 12卷附冊 (2015/06) Pp. 57-67

https://doi.org/10.6200/TCMJ.2015.12.SP.07

摘要

目的：拔除氣管內管，終止呼吸器，以減緩病人的痛苦折磨而達到善終目的，所作之撤除維生醫療需要有專業的素養、信仰及效率。2013年1月9日安寧緩和醫療條例三度修法後，撤除維生醫療在台灣是合法的。方法：本文為回溯性的研究，在一社區醫院收集自2014年1月1日至2015年3月31日共20例為了撤除維生醫療會診安寧團隊的案例，其中有3例是不符合條件而排除在外，其餘17例均詳細檢視病歷資料。為進一步分析這17例個案，依疾病診斷分為OHCA（醫院外心跳停止）及Non-OHCA（非醫院外心跳停止）二大組。結果：男性平均年齡為75.64歲，女性72.83歲；OHCA平均年齡為61.5歲，Non-OHCA 73.2歲。主要死亡原因第一位為醫院外心跳停止（OHCA），其次是慢性腎衰竭。緩和醫療家庭諮詢會議，每人平均1.35次。16位格拉斯哥昏迷指數（GCS）為2T。所有的不施行維生醫療同意書均由家屬簽屬，其中以子女簽署者最多（76.67%）。12位病人（70.59%）在安寧病房拔管，8位病人（67%）使用往生關懷室助唸8小時。拔管前，有13位病人（76.47%）使用morphine，14位病人使用Methylprednisolon針劑。拔管後有16位病人（94.12%）使用氧氣面罩。拔管至死亡時間，30分鐘內有5位（29.41%），12位病人（70.59%）在24小時內死亡，最短5分鐘，最長118小時。OHCA組及Non-OHCA組，拔管至死亡平均時間分別為12.5小時，26.5小時；會診安寧團隊至拔管的平均時間（準備期）則分別為79.8小時，55小時。17位病人讀取其健保IC卡均無DNR註記，住院前均無簽署預立安寧緩和醫療暨維生醫療抉擇意願書。拔管至死亡的時間因疾病不同而有異，OHCA組較短，而Non-OHCA組較長；準備期則OHCA組較長，Non-OHCA組較短。結論：為確保最佳品質的善終，撤除維生醫療前的準備以及撤除後的醫療照顧均相當重要，尤其是緩和醫療家庭諮詢會議的召開及家屬對病人的四道人生（道愛、道謝、道別、道歉）。除安寧病房外，獨立、隱蔽、溫馨的病室空間，予醫療團隊及家屬進行撤除維生醫療，同樣能達到高品質的善終。

關鍵字

撤除維生醫療 ； 拔管 ； 善終 ； 緩和醫療家庭諮詢會議 ； 四道人生

並列摘要

The withdrawal of life sustaining treatment-terminating mechanical ventilation and withdrawing of endotracheal tube to alleviate the pain and suffering of a patient for a peaceful death, requires professional adherence and efficiency. The Hospice Palliative Care Act, third amendment on January 9th 2013, legalizes the withdrawal of life sustaining treatment in Taiwan. We conducted a retrospective survey of withdrawal of life sustaining treatment in a community hospital from January 1st 2014 to March 31st 2015. Medical records of 20 patients with consultation of hospice palliative care team for withdrawal of life sustaining treatment were reviewed. Three cases were excluded because of non-qualification. The remaining 17 cases were divided into out-of-hospital cardiac arrest (OHCA) group and non out-of-hospital cardiac arrest (non-OHCA) group. The means of age of male and female patients were 75.64 and 72.83 years, while those of OHCA and non-OHCA group were 61.5 and 73.2 years, respectively. Regarding the major causes of death, the first on the rank was OHCA, and the second was chronic renal failure. The times for summoning family palliative care consultation meeting were 1.35 in average. The Glasgow Coma Scale in 16 patients was 2T. The consent form for extubation was signed by the family members in all 17 patients, of which 13 cases (76.67%) was signed by their children. The extubation procedures in 12 patients were performed in the hospice ward. Eight patients (67%) used bereavement room provided by hospice ward for an 8-hour chant according to Chinese culture. Intravenous morphine was prescribed for 13 patients and methylprednisolone for 14 patients before extubation. O2 mask was used in 16 patients (94.12%) after extubation. Regarding the time to death after extubation, 5 patients (29.41%) passed within 30 minutes, and 12 patients (70.51%) passed within 24 hours; the shortest period was 5 minutes, while the longest was 118 hours. The means of time to death after extubation in OHCA and non-OHCA group were 12.5 and 26.5 hours, respectively. There were no DNR remarks in health insurance cards of all 17 patients, meaning that no informed consent of withdrawal of life sustaining treatment was signed by the patients themselves before the date of admission. The means of time from extubation to death varied and were determined by the diseases suffered, which was shorter in OHCA group and longer in non-OHCA group. A good quality of death must be ensured through sufficient preparation, efficient withdrawal of life sustaining treatment, and aftercare, especially the family palliative care consultation meetings and four says of life of the family members to the patients (say love, say thanks, say good-bye, and say sorry). In addition to hospice ward, an independent, private, and warm room for performing withdrawal of life sustaining treatment, can also achieve a high quality of peaceful death.

並列關鍵字

life sustaining treatment ； mechanical ventilation ； extubation ； peaceful death ； palliative care