雙案例教學模式導入醫學倫理課程之成果－以長期呼吸器倚賴病人照護為例

本質性研究在呈現結合床邊案例體驗學習於經典案例小組討論之「雙案例教學模式」，導入臨床倫理教學課程之理論基礎及初步執行成效評估。本創新課程活動期待透過提供醫學生呼吸器倚賴病人床邊案例報告與討論之機會，導入較具多元視角的深度(in-depth)反思並進而產生深思熟慮的臨床決策。我們根據James Rest的界定議題測驗(Defining Issues Test, DIT)設計情境教案，作為帶領小組討論的教材。此課程第一個目標為引發學生對呼吸器倚賴病人照護議題的道德敏感度。此外，我們在小組活動中介紹學生如何運用Jonsen, Siegler, 及Winslade(2010)所提之臨床倫理四項主題，統整分析案例情境倫理判斷之相關因素，期能幫助學生發展出具有多元面相結構且有合理論述之案例分析。我們採用質性研究中樣板式分析及內容分析之方法，根據四項主題之樣版，對學生於課程中及課後的回饋與討論內容進行分析。質性資料編碼後，整理出639個學生根據情境案例所提論述。我們根據這些論述的相同性，將此639論述歸納成42個議題並依這四項主題進行分類。研究結果顯示在所有的小組討論中（共16組，165位學生），針對呼吸器倚賴病患面對DNR（不施行心肺復甦，Do not resuscitate）抉擇時，均能在四個面向上提出正反方之論點，進行多面向的思考。雖然各主題敘述的次數多寡不一，但學生在討論此議題時確實可以考量到醫療適應性、病人自主、生活品質與情境脈絡四主題內的正反方意見。我們從學生課後的反思內容中，發現學生皆覺察到病患家屬的看法對主治醫師進行醫療決策時會有哪些影響。

關鍵字

臨床倫理；醫學人文教育；呼吸器倚賴；反思寫作

並列摘要

TThis qualitative research aims at explicating the theoretical framework and preliminary outcome of implementing duo-case method (i.e., experiential learning of a bedside case following with small group discussion on a classic dilemmatic case) among Year-4 medical students. Multi-perspective in-depth reflection and clinical deliberation are anticipated to be developed through observing, presenting, and discussing patients under mechanical ventilator use. Rest's Defining Issues Test (DIT) was borrowed both for clinical scenario design and for group discussion. The learning objective of this course is to facilitate students' ethical sensitivity. ＂Four-Topic Approach＂ proposed by Jonsen et al. was also introduced to students for collecting relevant ethical issues and fostering a structured, sound and justifiable ethical case analysis. Moreover, based on the structure of four topics, template analysis and content analysis were used to analyze students' perspectives and feedbacks during and after the course. After data coding, 639 statements were identified and iteratively emerged into 42 main concepts locating within the four themes we have focused on. Our result shows that all of the 16 groups, which include 165 students in total, have explicated more than one argument in each theme to support or refuse to sign the DNR. Although disparity existed in between each group in terms of both quantity and quality of the rationales proposed, medical indication, patient preference, quality of life and contextual features have been all considered and addressed by each group. Further analysis on students' reflective portfolio showed that all students have acknowledged family's perspective on doctor's clinical judgment and decision.

並列關鍵字

clinical ethics ； medical humanity education ； ventilator-dependent ； reflective portfolio

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雙案例教學模式導入醫學倫理課程之成果－以長期呼吸器倚賴病人照護為例

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