非癌疾病的安寧療護：談COPD末期照護倫理

Non-Cancer Palliative Care Focus on Ethics of COPD Terminal Care

醫療科技高度發展的結果可以拯救病人於危急，卻亦可能讓病人因延長生命而承受極大痛苦。近年來在安寧療護與生死教育之推廣下已讓人審思如何極力避免此種後果。2009年9月起，中央健保局正式將八大非癌疾病的安寧療護納入健保給付，可望造福更多末期病人。本文謹就臨床胸腔專科及倫理之思考，探討慢性阻塞性肺病（chronic obstructive lung disease, COPD）末期照護的相關倫理議題。與癌症相較，COPD 的末期判斷更是充滿著不確定性。晚期COPD 的主要表徵是嚴重呼吸困難，須要即時判斷並且決定是否使用呼吸器。因此「不予」（withhold）或「撤除」（withdraw）的倫理決策，在COPD 病人身上，格外重要。醫療人員應引導病患提早思考末期時希望接受的醫療處置，並在深思熟慮下預立醫療指示（advance directives）或預立醫療指定代理人，讓醫療人員能在病患危急時，根據病患之意願，作出恰當之處置。目前安寧緩和醫療條例雖賦予醫師在病人臨終時，可依其意願或經最近親屬同意不予插管或不實施心肺復甦術，但對於已使用呼吸器之末期或臨終者卻無法由家屬代理決定終止或撤除，形成臨床上實務難題。藉由國外經典案例，作者期望以思考「標準治療」（standard treatment），「非常治療」（extraordinary treatment），以及「相稱性治療」（proportionate treatment）間不同之意義，在醫界取得呼吸器不應持續用在末期COPD 病人的共識，並提供將來安寧緩和醫療條例修法時之參考。透過本文，作者認為照護COPD之第一線醫療人員，除了傳統「盡力而為」（doing to）的心態外，還必須建立一個「與他同在」（being with）的病醫關係。除了幫助COPD 病人理解狀況，及早預立醫療指示或指定醫療代理人之外，亦要了解緩和療護身、心、靈整體照護之精神，以無接縫整合性照護模式，結合「治癒性治療」與「緩合性治療」，讓末期COPD 病患安祥的走完人生。

Recent development in medical technologies can save patients’ life but cause prolonged suffering in patients and families. The popularization of palliative medicine and life-and-death education has prompted people to consider how to avoid the above-mentioned consequences. To benefit more terminal patients, the Bureau of National Health Insurance has extended insurance coverage to include the palliative care of eight non-cancer terminal diseases. This article explored the related ethical issues regarding COPD terminal care, from the perspectives of thoracic medicine and medical ethics. Contrary to terminal cancers, the recognition and interpretation of signs of impending deaths of COPD patients are full of uncertainties. Besides, the most common terminal symptom of COPD is dyspnea, which requires the judgment and decision of using ventilator. Because of these, “withhold” and “withdraw” ventilator are the most important ethical issues in COPD terminal care. Health care workers (HCWs) should guide patients to consider deliberately about writing advanced directives early, so that HCWs can follow patients’ wills in critical situation. Presently, The Palliative Act allows physician to withhold trachea intubation and CPR according to patient and family’s wishes. Nonetheless, a previously-set ventilator cannot be legally withdrawn or terminated even with family’s wishes. This has caused tremendous difficulties in clinical practice. Through some landmark cases, the authors would like to differentiate between the terms “standard treatment,” “extraordinary treatment,” and “proportionate treatment,” and to discuss why a ventilator should not be continuously used as a life-sustaining treatment in terminal COPD care. We hoped that our argument can be accepted as a reference for the future legislation. The authors suggested that instead of the traditional relationships of “doing to”, the front-line HCWs should build a “being with” relationship with COPD patients. It would not only help COPD patient to understand the situations and to prepare their advance directives, but also reaffirm HCWs to apply the spirit of total palliative care. In doing so, a combination of curative treatment and palliative care may promote a peaceful dying of COPD patient.