高齡長者撤除維生醫療後之照護困境初探

目的：了解病人在撤除或終止維生醫療後未立即往生的情況下，醫療人員所面臨的臨床倫理困境，提供之後預立醫療諮商之實證資料及繼續教育方向，提升照護此類病人及家屬的醫療品質。方法：以2017年1月至8月入住國立臺灣大學醫學院附設醫院期間曾照會安寧緩和共同照護團隊進行維生醫療撤除或終止評估個案當中，大於65歲撤除維生醫療後未立即（＞24小時）死亡之老年病人的病歷為收案來源。採回溯性病歷回顧研究，蒐集並進行資料登錄，包括基本資料（人口學資料、過去病史及社會層面史等）、臨床重要實驗室數據(APACHE II score)、撤除或終止的維生醫療選項，並根據病歷內容、醫師照會及護理師訪談記錄進行倫理困擾之判斷及登錄。結果：有五位高齡長者撤除維生醫療後未立即死亡，分別為兩位男性及三位女性，平均年紀為71.8±9.9歲，住院平均天數為17.8±11.7天，入院時以APACHE II score評估的死亡率平均為62%；在維生醫療方面，五位病人皆有呼吸器的使用，其中四位有使用升壓劑且有輸血紀錄，一位接受洗腎。三位的意識狀態為警覺，兩位為昏迷狀態。平均入住13.2±9.28天後決定撤除/終止維生醫療。病人平均於撤除維生醫療（拔管）後3.8±2.16天死亡，撤除/終止維生醫療前後使用藥物種數差別不大(前：11.2±5.4種，後：10.2±5.49種)。撤除/終止維生醫療後，當中有三位病人停止動脈穿刺、停用升壓劑，三位病人停止抽血，兩位病人停止靜脈輸液、靜脈營養跟抗生素的使用，只有一位是停用中央靜脈導管。撤除維生醫療後最常見的症狀為喘、其次才是疼痛跟躁動。對照在撤除/終止維生醫療後，臨床照護上最常面臨到的困境為嗎啡類藥物的使用議題。結論：高齡長者撤除/終止維生醫療後未立即死亡常遇到的臨床照護困境包括多重用藥、抗生素的使用以及撤除/終止維生醫療後症狀的控制；溝通困境則常為病情告知跟善終地點的選擇。

關鍵字

撤除或終止維生醫療；倫理議題；臨床照護困境

並列摘要

Purpose: Physicians frequently face clinical difficulties when caring for older patients who do not pass away within 24 hours after the withdrawal of life-sustaining treatment. Understanding the ethical dilemmas encountered by physicians under such a circumstance would help improve the communication and decision-making process in end-of-life care. Methods: Cases withdrawing life-sustaining treatment were identified from hospice shared care records in a medical center in Northern Taiwan from January to August 2017. Background information, clinical indicators, records of physicians, nursing staffs, and clinical ethical dilemmas were collected from retrospective chart review for analysis. Results: Among the patients (＞65 years old) consulting the center's palliative care services team for withdrawing or withholding life sustaining treatment during the study period, 5 patients did not die within 24 hours while 11 patients died immediately (within 24 hours). For the five cases, the average days of hospital stay were 17.8±11.7 (Mean± SD) days, the average duration before the withdrawal of life-sustaining treatment was 13.2±9.28, and the death occurred 3.8±2.16 days after the withdrawal of life-sustaining treatments. No difference in number of medication was noted before (11.2±5.4) and after (10.2±5.49) the withdrawal of life-sustaining treatment. The most common symptoms in these patients were dyspnea, pain, and delirium. The most frequently encountered ethical dilemma concerned the use of morphine. Conclusion: The most frequent ethical dilemmas for caring patients who do not die within 24 hours after the withdrawal of life-sustaining treatments include polypharmacy, use of antimicrobial agent, and insufficient symptoms control. The preferred place for end-of-life care and truth telling appear to be the most concerned issues during family conference for decision making on further treatment strategy.

並列關鍵字

life sustaining treatment ； withdrawal ； withhold ； ethical dilemmas

國際替代計量

高齡長者撤除維生醫療後之照護困境初探

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