協助重症末期病人之家屬運用「家庭賦權」於醫療抉擇過程

本文探討一位加護病房之末期出血性中風個案無預立醫囑，家屬代為進行醫療抉擇，面對「不予」及「撤除」心肺復甦術或維生醫療產生抉擇衝突之過程。加護病房時間是急迫且壓縮的，面對親人即將死亡，在悲傷與衝突的情緒下，需於慌亂的時間裡做出醫療抉擇，由積極搶救、不施行心肺復甦術、乃至維生醫療的不予甚至撤除等，呈現高度多樣多變性。文中個案家屬雖為醫護相關背景，面對生死醫療抉擇仍然是充滿無知和恐懼。筆者運用「家庭賦權」的策略：家庭決策者角色覺醒、評估家庭問題根源、設定具體目標、資源連結、應用與行動及結果評價等協助家屬進行醫療抉擇。照護過程中筆者與家屬建立信任感，做為醫療團隊溝通橋梁，使家屬能充分了解病情與醫療極限，全程陪伴家屬渡過個案臨終前歷程，並配合家庭宗教與文化提供個別化的臨終照護。末期醫療抉擇倫理議題無標準答案，最重要的是抉擇過程賦予家屬的意義及如何因應個案臨終後生活。期望藉由本文照護經驗，提供其他加護病房護理師參考，一起為提升加護病房重症末期照護品質努力。

關鍵字

重症末期；加護病房；醫療抉擇；家庭賦權

並列摘要

This article discusses the process to assist a family make a medical decision on life-sustaining and resuscitation treatments for a terminally-staged hemorrhagic stroke patient who did not have a written medical advance directive on file. Medical decisions during resuscitation range from active rescue, not performing CPR, withholding, and withdrawing life-sustaining treatments. The family lacked understanding of withholding vs. withdrawing life-sustaining treatments. The fast pace in ICU presented challenges during imminent death of a loved one; therefore, medical decisions tended to be made in a haste and with emotional conflicts. In spite of the family’s knowledge in the medical field, they exhibited fear and were powerless when faced with life and death medical decisions for the patient. Applied were “family empowerment” strategies to help the family, including reinforcing the role of the family decision-maker, assessing the root causes of issues, setting specific goals, connecting/use of resources, and evaluating action effects. The establishment of mutual trust and bridged communication between family members and the medical team enabled the family to understand the patient’s medical condition and the medical limitations. The care process included providing individualized physical, cultural and religious care and companionship to the whole family throughout the process. The principles of ethics for medical decisions were followed during the terminal stage, and the family was helped to understand the decision-making process and coping after the patient passes. This care experience is expected to serve as a reference for other ICU nurses to provide quality of care for patients in a terminal stage.

並列關鍵字

terminal ； intensive care unit ； decision making ； family empowerment

參考文獻

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Browning, A. M. (2009). Empowering family members in end-of-life care decision making in the intensive care unit. Dimensions of Critical Care Nursing, 28(1), 18-23. doi:10.1097/01.DCC.0000325092.39154.4a

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Waldrop, D. P., Meeker, M. A., Kerr, C., Skretny, J., Tangeman, J., & Milch, R. (2012). The nature and timing of family provider communication in late-stage cancer: A qualitative study of caregivers’ experiences. Journal of Pain and Symptom Management, 43(2), 182-194. doi:10.1016/j.jpainsymman.2011.04.017

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協助重症末期病人之家屬運用「家庭賦權」於醫療抉擇過程

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