助人者與癌症末期病人關係歷程之質性研究

The process of helping relationships between the helper and the terminally ill cancer patients at hospice in Taiwan-- A qualitative research

李佩怡(Pei-Yi Li)

指導教授 ： 金樹人

國立臺灣師範大學/教育學院/教育心理與輔導學系/博士(2002年)

摘要

助人者與癌症末期病人關係歷程之質性研究
研究者：李佩怡
摘要
本研究探討一位助人者與四位癌症末期病人之關係歷程。研究目的有三大部份：一是理解助人者與癌末病人之關係歷程的本質與進展要素；二是理解癌末病人身心靈社會四部份的經驗；三是理解與反思助人者接觸癌末病人之個人經驗。
本研究在計畫階段特別經過馬偕紀念醫院安寧療護教育示範中心及安寧緩和醫學學會之聯合倫理委員會，雙重的「機構審查委員會」（IRBs）的審查通過，才開始進行正式研究。本研究是以詮釋學為方法論，對助人者與四位癌末病人的「對話逐字稿」及「田野日誌」等原始資料進行詮釋，研究結果是研究者在詮釋原始資料過程中以「理解—再理解」的詮釋循環所獲致的深刻理解，及「辯證式提問」獲致包覆性理解提出的綜合詮釋。
本研究結果分為下列三大部份：
一、對助人者與癌症末期病人關係歷程，提出「關係本質」、「關係進展關鍵要素」、及「關係歷程中重要議題」等三大部份。助人者與癌末病人的關係本質是：「真實的人與人相遇」、「雙向平衡的互動」、「相互信任、人性情感，及穩固的連結」。助人者與癌末病人關係進展的關鍵要素是：「對病人內在世界的深入理解」及「接觸焦點是跟隨病人全人狀態的變動而移動」。在助人者與癌末病人關係歷程中所出現的重要議題有下列七項：「照護癌末病人生理需求」、「癌末病人需要談其因癌症所受的苦」、「癌末病人需要談現實生活中的苦」、「癌末病人需要倚靠希望、訴說希望」、「面對死亡，病人也許求助於更高更大的力量，或期望與某個『超個人對象』緊密連結，以獲得安全、愛，及力量」、「癌末病人在臨終過渡的過程中所需要是力量」、「當病人越來越衰弱時，其家人浮現被支持的需求」。
二、對癌症末期病人的身、心、靈、社會四大層面提出深入詮釋，並於綜合詮釋的部份提出「臨終過渡期七大現象」，「社會層面為身心靈三層面的基礎」，「末期病人由外在世界轉入內在世界」，及「癌末病人虛無存有」等詮釋概念。
三、對助人者的內在經驗深入詮釋，其中包括：「助人者的認知經驗的解構與再建構」，「情緒經驗的統整與轉化」，及「助人者自我轉化」等。其中助人者「個人整體的轉化」有三大部份：由諮商心理專業者走向人道主義者、由理智分析作為者走向情感思維的分享者、對自己的「有限性」，由模糊不清到跨越與接納。
最後本研究分別對「助人工作者的自我準備」、「照護癌症末期病人」、「安寧療護制度：日間留院設置刻不容緩」、「未來研究」、「諮商教育」提出建議。研究者衷心建議所有照護癌末病人的家人、親友、照顧者、醫療專業者，重視自己與病人之間的關係，鼓勵維繫一份真實、穩固、信任、平等、尊重、富有人性情感的關係，這對癌末病人的末期生命，意義非凡！
關鍵字：癌症末期病人、安寧療護助人工作者、關係歷程、詮釋學

關鍵字

癌症末期病人 ； 安寧療護助人工作者 ； 關係歷程 ； 詮釋學

並列摘要

The Process of Helping Relationships between the Helper and the Terminally Ill Cancer Patients at Hospice in Taiwan—
A Qualitative Research
Pei-Yi Li
ABSTRACT
The purpose of this study was to investigate the process of helping relationships between the helper and four terminally ill cancer patients who accepted palliative care at the Mackay Memorial Hospital. The specific aims of the study were: (1) to understand the essence of the helping relationships and the key elements of facilitating the helping relationships; (2) to understand the living experiences of terminally ill cancer patients; (3) to understand and reflect the personal experiences of the helper after encountered with four terminally ill cancer patients.
The study was approved by the「 Institutional Review Boards of Mackay Memorial Hospital」 and the「 Joint Ethics Boards of Taiwan Academy of Hospice Palliative Medicine」. A hermeneutical approach was selected to achieve the purpose and specific aims. The data was collected from the beginning of the relationships till the end of the patient life. The raw data was generated from the in-depth unstructured interviews between the helper and four terminally ill cancer patients in the natural settings, as well as the field notes by the helper jotted down after the meetings. With the permissions of the four dying patients, most of the natural talks were taped and than had been transcribed into words. The transcriptions and field notes were interpreted following the hermeneutical concepts. Through the thick description, the hermeneutical circle of understanding and the dialectical questioning, the deep understanding of the raw data was obtained.
Regarding to the helping relationships, the results of this study included three main parts. First, the essence of the helping relationships included 3 themes: (1) the two persons encounter with each other genuinely; (2) the balancing and collaborative interactions; (3) the steady connection with mutual trust and humanity.
Second, the key elements of facilitating helping relationships included 2 themes: (1) keeping the deep understanding towards the inner world of dying patients; (2) keeping the contact with dying patients according as the changing situations and the wholeness of patients.
Third, there were seven important issues emerged from the process of helping relationship, as namely: (1) to take care of terminally ill cancer patients’ physical needs with gentle attitudes; (2) to listen actively to the suffering of terminally ill cancer patients owing to the destructive illness; (3) to listen actively to the difficulties of terminally ill cancer patients in their lives; (4) to encourage the terminally ill cancer patients to describe their hope; (5) to facilitate the terminally ill cancer patients to connect with their spiritual objects; (6) to help the terminally ill cancer patients to find their strength inside; (7) to support the family members facing the reality of patients’ weakness and impending death.
Regarding to the living experiences of terminally ill cancer patients, the main concepts were: (1) 「the phenomena of dying transition」; (2) 「the existence of dying patients dependent upon their social network」; (3) 「the concernment of dying patients changing from outside world into inside world」; (4) 「the concept of non-being-in-the-world」.
Regarding to the personal experiences of the helper, there were three parts of description, including: (1) 「the destruction and reconstruction of the helper’s cognition concerning about counseling with dying patients」; (2) 「the integration of the helper’s emotions」; (3) 「the transformation of the helper’s personhood」.
Through the findings of this study, some recommendations were given to the helpers who work in hospice, concerning about how to prepare himself/herself becoming a good helper and how to take good care of terminally ill cancer patients. Moreover, the researcher suggested that the hospice day care center should be established quickly in Taiwan. The hospice day care center could provide more supportive networks to the dying patients, so that they could live with pleasure and meaning. Finally, the researcher emphasized that all the caregivers who take care of terminally ill cancer patients should concern their relationships with dying patients, especially family members, friends, and health professionals. Being a helper, the researcher recommended the we should cherish our relationships with the dying patients, to contain a steady connection with them, to build mutual trust with them, to interact with them collaboratively, and to take care of them with humanity. If we could be genuine helpers, the relationships with dying patients will be magnificent!
KEY WORDS: terminally ill cancer patients, the helpers in hospice, the helping relationships, the hermeneutical circle

並列關鍵字

terminally ill cancer patients ； helpers in hospice ； helping relationships ； hermeneutical circle