慢性阻塞性肺病末期病人使用限期嘗試性治療的照護經驗

Experience of Time-limited Trail in Care of Terminal Patients with Chronic Obstructive Pulmonary Disease

黎瑞萍(Jui-Ping Li) ； 李淑靜(Shu-Ching Li) ； 陳巧萍(Chiao-Ping Chen) ； 王寧道(Ning-Tao Wang) ； 洪宗杰(Tsung-Chieh Hung)

《安寧療護雜誌》 17卷2期 (2012/07) Pp. 210-221

https://doi.org/10.6537/TJHPC.2012.17(2).7

摘要

本文個案是位老礦工，已有呼吸困難症狀數年，加上長期抽菸併發慢性阻塞性肺病（chronic obstructive pulmonary disease, COPD），病程持續進展到需要依賴他人完全照顧，住院頻率增加，時間也一次比一次久，生活品質持續不斷惡化。個案在就醫期間，陸續清楚明確的向醫師表達，拒絕插管使用呼吸器來延長生命的意願。家屬及個案對末期階段的醫療計畫及要求是不同步的，令醫療團隊夾於個案與家屬間陷入兩難。此次個案發生呼吸衰竭面臨須插管使用呼吸器，考量其慢性阻塞性肺病末期判斷不易且醫療處置不確定絕對有利的情況下，嘗試安寧緩和醫療意願書加註限期嘗試性治療（time limited trial）的簽立，協助個案、家屬與醫療團隊緩解困境，依共同協議的疾病末期醫療計畫進行醫療照護。最後，個案在家屬陪伴下返家，安祥的往生。此案例浮現了在尊重病人自主權與家屬醫療期盼不一致的衝突。而限期嘗試性治療的加註，提供了彈性與空間，讓病患、家屬及醫療團隊等三方達成共識，使醫療照護能順利進行。

關鍵字

慢性阻塞性肺疾病 ； 呼吸器 ； 醫療意願書 ； 末期病人 ； 限期嘗試性治療

並列摘要

This article is about an old coal-miner, who's having intermittent respiratory distress for several years. He is also a heavy cigarette smoker, and complicated with chronic obstructive pulmonary disease (COPD). His disease status deteriorated, and symptoms became more severe and prominent. He needed total care. Hospitalization became more frequent and duration of stay became longer. The quality of life of this patient continued to deteriorate. Although the patient had clearly expressed the refusal of endotracheal intubation, no official documentation was made. Meanwhile, the family's opinion opposed that with the patient, which made it difficult for the medical staff to deal with. He developed respiratory failure despite the use of NIPPV, and conducted trial of time-limited intubation and mechanical ventilator use, which is compatible with care of the terminal COPD patient who wishes to have extubation if no improvement noted. The patient's condition deteriorated, and on the 13th day of ventilator use, he was extubated and palliative treatment was done. After discussion with the family members, he was brought home for peaceful death. This combination of hospice care and time-limited respiratory trial therapy has helped resolving the conflict between the patient's will, the family's expectations and the concepts of the medical team. The flexibility and time given in this method, is an easy access in aiding to achieve satisfactory result agreeable for the 3 parties, at the same time able to perform proper medical care. Therefore, we share this experience for use of this method in care of terminal COPD patients.

並列關鍵字

Chronic Obstructive Pulmonary Disease (COPD) ； ventilator ； end stage patient ； time limited trial