緩和鎮靜於末期病人存在性受苦之照護倫理與臨床處置思辨

Palliative Sedation for Existential Suffering among Terminally Ill Patients: The Care Ethics and Clinical Debates

馬宜君(Yi-Chun Ma) ； 賴維淑(Wei-Shu Lai)

《安寧療護雜誌》 25卷3期 (2021/07) Pp. 239-252

https://doi.org/10.6537/TJHPC.202107_25(3).03

摘要

緩和鎮靜（palliative sedation, PS）在緩解臨終病人的難治性症狀扮演重要角色，但以PS來控制難治性存在性受苦仍存有爭議。本文基於生命倫理辯證文獻，系統地定義、描述、分析和討論以緩和鎮靜來控制難治存在性受苦之倫理爭議和基礎概念，闡釋緩和鎮靜目前的現況、定義與適用條件，並提出存在性受苦的概念，以雙果效應、比例原則、醫學倫理四原則探討緩和鎮靜在存在性受苦（palliative sedation for existential suffering, PS-ES）的使用考量，並提出醫療照顧者可能面臨的掙扎與臨床照護建議。透過藥物解決存在性受苦並非優先選擇，須確認周全性跨專業團隊照護處置已用到極致，PS的目的並非滿足病人暫時想要減除意識以及永久終止生命的渴求，醫療照護者須對使用緩和鎮靜的適應症及潛在的原因進行全面地評估並協助緩解受苦，期能提供臨床實務的參考。

關鍵字

末期病人 ； 存在性受苦 ； 緩和鎮靜 ； 安寧緩和療護 ； 倫理

並列摘要

Palliative sedation (PS) plays a critical role in the refractory symptom relief of dying patients; however, using it for controlling refractory existential suffering is controversial. The present article aimed to systematically identify, describe, analyze, and discuss ethical arguments and concepts underpinning the argument-based bioethics literature on palliative sedation for existential suffering (PS-ES). We elaborated the current situations, definitions and indications of palliative sedation, and proposed a concept of existential suffering. Furthermore, the ethical principles of double effect, proportionality, and the four principles of biomedical ethics were used in argumentations in the PS-ES debate. We illustrated the struggles that healthcare professionals may confront in the patients' circumstance of existential suffering and provided recommendations for clinical care. Resolving existential suffering through drugs is not the first choice. It must be confirmed that comprehensive multi-professional team care and treatment have been used to the extreme. The purpose of PS is not to satisfy the patient's desire to temporarily eliminate consciousness and permanently terminate life. Medical professionals need to comprehensively assess the indications and potential causes of palliative sedation and help alleviate suffering. We hope it can provide as a reference for clinical practice.

並列關鍵字

terminally ill patients ； existential suffering ； palliative sedation ； palliative care ； ethics

參考文獻

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Ciancio AL, Murza RM, Ciancio AA, Klinger CA. The use of palliative sedation to treat existential suffering: a scoping review on practices, ethical considerations, and guidelines. J Palliat Care 2020; 35(1): 13-20.

Rodrigues P, Menten J, Gastmans C. Physicians’ perceptions of palliative sedation for existential suffering a systematic review. BMJ Support Palliat Care 2020; 10(2): 136-144.