協助一位末期病人臨終出院之照護經驗

落葉歸根在宅善終為華人傳統文化信念，但常因家屬諸多考量致使無法完成此心願，本文為協助臨終病人返家善終完成心願之護理經驗。照護期間為2019年10月19日至24日，藉由身體評估、觀察、溝通技巧，整體性評估生、心、社會、靈性需求，統整病人的健康問題有：（1）多發性感染；（2）家屬擔心臨終出院之善終照護；（3）預期性哀傷。以病人為中心擬訂個別性護理計畫，考量病人餘生期待與存活預估，權衡醫療處置之利弊得失，與家人共同討論在臨終階段停止給予抗生素及人工營養與水分，傾聽家屬對於返家善終之擔憂，教導家屬辨識瀕死症狀與臨終返家善終準備，跨專業偕同宗教師、音樂治療師運用生命回顧肯定病人的價值和已完成的人生目標，引導病人與家屬情緒表達與四道人生，提供預期性哀傷撫慰。臨終出院在宅善終須要及早擬定照護計畫，並於返家後持續提供醫療後盾及持續性的幽谷伴行，希冀藉由此照護經驗的分享，作為臨床照護之參考。

關鍵字

末期病人；臨終出院；善終準備；預期性哀傷

並列摘要

Dying at home, which is similar to a fallen leaf returning to its root, is a traditional Chinese cultural belief. However, due to the various considerations of the family, the wish to die at home is often unfulfilled. This article describes the nursing experience of helping a terminally ill patient to terminal discharge from the hospital and to fulfill his wishes to die at home. The period of nursing care experienced herein ranged from October 19-24, 2019. Three major health problems were identified: 1) multiple infections; 2) family members' worries about pre-dying care at home after terminal discharge; and 3) anticipatory grief, which was assessed through physical assessment, observation, communication skills, and an overall assessment of the patient's physical, psychological, social and spiritual needs. A patient-centered individualized nursing plan was developed. Considering the patient's life expectancy and survival prediction, as well as the merits and demerits of medical treatments, discontinuation of antibiotics, artificial nutrition and hydration at the pre-dying phase were discussed with family members. The healthcare professionals also empathized with the family's worries regarding the patient's death at home and instructed the family to identify pre-dying symptoms and make death-related preparations at home. Interprofessional collaboration with a spiritual care provider and a music therapist using life reviews to affirm patient's value and achievements guided patient and families to express their emotions and four themes of life (gratitude, apology, love and goodbye). These healthcare professionals also provided anticipatory grief care. Terminal discharge to die at home requires advance planning of care, continuous provision of medical services, and companionship for the patient. It is hoped that this nursing experience can be used as a reference for clinical care.