成人加護病房護理人員提供善終照護模式之探討

Exploration of Good Dying Care Model:Perspective of Taiwan's Nurses in Adult Critical Care Units

許美柔(Mei-Jou Hsu)

指導教授 ： 林佳靜

共同指導教授 ： 施富金

臺北醫學大學/護理學院/護理學研究所/碩士(2008年)

https://doi.org/10.6831/TMU.2008.00102

摘要

本研究目的是希望透過臨床加護病房護理人員的觀點，瞭解國內成人加護病房護理人員對善終照護的看法、影響成人加護病房護理人員提供病患善終照護的因素、成人加護病房護理人員照顧臨終病患所需要之協助及成人加護病房病患獲得善終之照護指標，以提供加護病房臨終病患一個兼具文化及整體性的照護。
本研究採綜合研究法，針對北部某醫學中心之成人加護病房護理人員為收案對象，使用自擬問卷進行調查，問卷結果以描述性統計、t檢定、單因子變異數分析、皮爾森積差相關及質性內容分析法進行整理。
目前加護病房護理人員照顧臨終病患可分為四個時期--第一期：醫療團隊初步確定病患病情不樂觀、第二期：疾病治療效果不佳，與家屬溝通病患極可能死亡、第三期：預備病患臨終、第四期：病患臨終，每一期都有不同的重點但均包含病患及家屬的身心靈照護。其照顧內涵包括：護理評估力、醫療決策的參與度及護理照護行為三大範疇；其中加護病房護理人員對臨終病患整體照護行為的預測因子為：整體護理評估力、整體醫療決策的參與度、加護單位年資及自覺宗教信仰虔誠度。
在影響成人加護病房護理人員提供病患善終照護的因素可分成正負向因素，正向因素：良好的護理專業能力、認同護理是一份助人的工作及獲得醫療團隊的支持；負向因素：護理時間受限、未獲得醫療團隊的支持、缺乏提供善終的環境、無法談論死亡。
在提供成人加護病房護理人員照顧臨終病患所需要協助則是希望建立常規性討論會促進醫師、護理人員、病患及家屬三方面的溝通，提供關於緩和醫療的在職教育及法律議題為主。
最後希望建立加護病房的善終指標為：病患臨終前，能有效緩解不適的症狀（例如：喘、疼痛）、病患能得到有意義他人的支持、意識清楚的病患其心願能適度表達、病患對病情的瞭解能與家屬一致、病患臨終時間未做無意義的拖延或因不當醫療照護而提前、病患及家屬能得到所需宗教的協助、家屬能反應醫院可提供相關資訊協助家屬進行後事的準備、病患能呈現情緒平穩，沒有消極負面的言語表達。

關鍵字

成人加護病房；護理人員；善終

並列摘要

The purpose of this research is to understand the current state of the nursing model to take care of dying patients in adult intensive care units (ICU), to realize the factors influencing nursing staffs’ decision to provide good death care, to identify the help that nursing staffs need to provide good death care for dying patients, and to find out goals for patients in adult ICU to acquire good death care in order to establish a model with the culture and the over-all medical system, based on the viewpoint of clinical nurses in ICU.
This research adopts “between method triangulation”, targeting nursing staffs of adult ICU in a medical center in northern Taiwan and sending questionnaires to them to collect information. The data is analyzed by descriptive statistics and qualitative content analysis method.
Current nursing staffs in ICU to take care of dying patients could be divided into four periods: first, a medical team assesses that the condition of the patient is not optimistic; secondly, the response to medical care is not good, and the family of the patient has been informed of the possibility of death; thirdly, preparing for the patient’s death; and fourthly, the patient’s approaching death. There are different focuses in different periods; but nonetheless, they all include physical and mental care of the patient and his family. The content of care includes three perspectives: the nursing capacity of evaluation, the participation in medical decision, and caring conduct by nurses. Moreover, the predictive factors for ICU nurses to care dying patients are: the nursing capacity to evaluate, the participation in medical decision, the seniority of the ICU unit, and the self-consciousness of devotion to religion.
The factors to influence nursing staffs in adult ICUs to provide good dying care could be divided into positive and negative ones. Positive factors include: good professional ability of nursing staffs, the recognization that nursing is a job to help people, and to obtain the support of the medical team. In contrast, negative factors include: limited time of nursing, the shortage of support by the medical team, the lack of environment to provide good dying care, and the inability to talk about death.The help needed by nursing staffs in adult ICUs is to have regular meetings to improve the communication among doctors, nursing staffs, and the patient and his family as well as to provide on-the-job training and legal information about good death care.
Lastly, the goals to provide good death care in ICU are: to alleviate uncomfortable symptoms (such as dyspnea or pain), to ensure that the patient can acquire meaningful support by their parties, to help conscious patient to express his wishes, to make sure that the patient and his family have the same understanding about the illness, to ascertain the time of death would not be delayed for meaningless reasons or arrive earlier due to inappropriate medical care, to help the patient and his family to receive religious support, to provide information and to assist the patient’s family to prepare funeral affairs, and to keep stable the mental state of the patient and to avoid negative verbal expressions.

並列關鍵字

Adult Critical Care Units ； Nurse ； Good dying

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