精神衛生醫護人員之倫理困境及其處置

Ethical Dilemma and Treatment :A Study of Psychiatric Mental Health Physicians and Nurses.

劉美珍(Meei-Jen Liu)

指導教授 ： 劉仲冬 博士

臺北醫學大學/醫學院/醫學科學研究所/碩士(2001年)

摘要

醫護人員在精神醫療過程，經常會面臨臨床實務的倫理困境，而中外研究皆指出倫理困境會讓醫護人員產生負向感受與心理不平衡，並影響團隊士氣及照護品質。本研究目的，在探討精神衛生醫護人員所遭逢倫理困境的議題、原因、影響及處置的脈絡過程，以作為臨床醫療人員處理倫理困境之參考途徑。同時，能關注及重視個案自主權利與生命價值。 本研究以臺灣某精神專科醫院急性病房之醫護人員為研究對象，應用質性研究的參與觀察法與深度訪談收集資料，以及用持續比較分析法，進行資料的分析與處理。 研究結果發現精神衛生醫護人員之倫理困境，大都來自三方面：其一是醫護人員的價值觀及專業角色，其次是法令制度，包括政府的健保制度、社會的法條、安全與資源以及醫院的政策、管理制度，再者是醫（護）病關係與病人的權利義務，包括醫護衝突、家屬需要及治療信任關係。而困境議題，含括強制住院、開立診斷書、藥物問題；開藥、用藥與副作用、電氣痙攣治療（ECT）、自動出院、約束隔離處置以及安置議題。同時，發現醫護人員最主要的倫理困境，是醫院制度之人力不足、訓練系統缺乏以及缺乏支持，醫師是【治癒有極限】，即精神醫療的極限，護理人員是缺乏理性分析的決策判斷能力及對病人問題行為的管理能力，而家屬是精神醫療的重要決策者以及病人自主權利為前三者所忽略、所剝奪。 本研究依研究發現，提出下列建議: 一.醫護教育方面 1.做系統性倫理與人文教學的課程規劃。 2.強調教學策略與臨床實務的配合。 二.臨床實務方面 1.加強臨床困境的在職教育。 2.單位基層主管應關心、支持及協助醫護人員，定期研討實際案例，以建立正確疏通倫理困境的管道。 3.成立病房『倫理問題討論會』或併入醫療會議中，討論面臨的倫理困境問題。 三.醫院行政方面 1.成立『醫療倫理委員會』。 2.增強臨床專業與倫理決策能力，以提升照護品質。 關鍵字:精神衛生醫護人員、倫理、倫理困境、倫理決策、處置。

關鍵字

精神衛生醫護人員 ； 倫理 ； 倫理困境 ； 倫理決策 ； 處置

並列摘要

The psychiatric physicians and nurses had encountered ethical dilemma of clinical practice. There were many studies related to ethical dilemma that could not only induced negative feelings and psychological disequilibrium, but also influenced multidisciplinary team practices and the quality of patient care. The purpose of the study was to explore the contextual process of ethical dilemma issues，factors，effects and treatment and provide suggested solutions for physicians and nurses. It could concern patients’ autonomy and value of life in the same time. The samples came from the physicians and nurses of acute ward in a psychiatric hospital in Taiwan. The study, applying qualitative research method, used participant observation and in depth interviewing to generate;constant comparative method of qualitative analysis. The findings of this study contained three portions of ethical dilemma. First，value and professional role of physicians and nurses. Second，legal and institutional difficulty whcih included health insurance of government，legal，security，resources in society and institutional policies，management in hospital. Furthermore, physicians（nurses）-patients relationship and rights and obligations of patients.；that included physicians —nurses conflict and rapport. Then，there were involuntary admissions ，diagnosis document ， medical problems including order sheet and drug effects and related adverse reactions, ECT（electroconvulsive treatment）, AAD（against advice discharge）, seclusion and restraint, and long term hospitalization were the issues of ethical dilemma .Then, the major ethical dilemmas of physicians and nurses in hospital that lacked of persons ,training system and support. Limitation of cure in psychiatric treatment of physician. And lacked of rational analysis for judged ability of decision making and managed problematic patient behaviors. The family was as decision-maker in psychiatric treatment of patients. So that the patients’ autonomy had neglect of physicians, nurses and family. According to these findings，our suggestions were： 1.Dimension of medical and nursing education；To plan the systems in curriculums of ethical issues and human subjects. And to emphasize the match of education and practice. 2.Dimension of the clinical practice：To enhance the working training of dilemmas. Administrators should be aware that physicians and nurses those whom must be supported and helped to cope with moral distress in actual situations. And to established『the ethical rounds』at ward. 3. Dimension of the administration in hospital ：To established『the ethical committees』.And to enhance the ability of profession and ethical decision making so that to highlight the quality of patient care. Key words ：Psychiatric mental health physicians and nurses；Ethics； Ethical dilemma； Ethical decision making；Treatment.

並列關鍵字

Psychiatric mental health physicians and nurses ； Ethics ； Ethical dilemma ； Ethical decision making ； Treatment

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