緩和醫療照顧的倫理困境

Ethical Dilemmas in Palliative Care: a Multicenter Study

近十年來，國內安寧療護及緩和醫療照顧因應需要而如火如茶推展，但卻有不少論理兩難困境困擾工作人員、病人及家屬，因此極需加以探討及規範。其中又以調查及探討國內癌末照顧倫理困境及其影響因素為當務之急。本研究據此目的而針對國內十家安寧病房，施以結構式問卷調查，共有八家安寧病房112位同仁回覆，其中76位(67.9%)為護理人員，26位(23.2%)為醫師，平均照顧癌末病人期間為21.9±24.5個月，而超過六成(62.5%)回應者對癌末照顧工作滿意。研究結果包括：倫理困境遭遇頻度依平均值高低排序為：1. 家屬不願讓病人知道真相（2.90±1.06，0~5分）；2. 病人漸不能攝食時，是否經由靜脈輸液(2.90±1.41)；3. 與病人期望的照顧目標有差距(2.81±1.15)；4. 病人不了解病情真相產生的困擾(2.73±1.20)及5. 家屬拒讓病人出院的困擾(2.60±0.98)。而困擾程度依平均值高低排序為：1. 病人自覺無法治癒，陷入絕望不易輔導（3.05±1.05，0~5分）；2. 家屬拒讓病人出院的困擾(2.97±1.09)；3. 家屬不願讓病人知道真相(2.93±1.03）；4. 面臨人力不足及不穩定之困擾(2.87±1.40)及5. 病人症狀控制成效不佳(2.83±0.96)。至於各基本資料變項如性別、個性、工作年資、專業別及宗教別的倫理困境並無明顯之差別。本研究顯示的意義：1. 安寧病房提供癌末照顧時，發生許多倫理困境，其困擾的產生常因專業研究證據不足，無法適時提供治療決定的根據。2. 照顧團隊加強提供整體性照顧的能力，有助解決嚴重倫理困擾事件。3. 工作人員如能定期接受倫理問題探討及解決的訓練，有助癌末照顧品質的提昇。4. 研擬適合國內癌末照顧指引，可減少倫理困境之困擾程度，有助安寧療護及緩和醫療目標之達成。

Many ethical dilemmas that arise in hospice care unit may hinder the efforts of health professionals to ease suffering and allow 'good dying' for terminally ill cancer patients. Investigating the ethical dilemmas and establishing the regulations and guidelines in hospice and palliative care may be some of the most important issues for hospice development in Taiwan. Accordingly, we conducted a multicenter questionnaire study to investigate the frequency and causes of ethical dilemmas in hospice and palliative care units. A total of 112 professionals from eight of the 10 hospices nationwide responded. Seventy-six out of the 112 respondents (67.9%) were nurses while 26 were physicians (23.2%). The mean period of providing hospice care was 21.9±24.5 months. Sixty percent of the respondents were satisfied with their work. The most commonly encountered dilemmas were 1) family refusal to tell the patient the truth (2.90±1.06,range: 0~5); 2) when to hydrate patients (2.90±1.41); 3) discord between patients and professionals in terms of the goals of treatment (2.81±1.15); 4) patients being aware of the truth (2.73±1.20); and 5) family refusal of the discharge plan for patients (2.60±0.98). The most difficult dilemmas were 1) difficulty in providing psychospiritual care (3.05±1.05,range:0~5); 2) family refusal of the discharge plan for patients (2.97±1.09); 3) family refusal to tell the patient the truth (2.93±1.03); 4) insufficient manpower (2.87±1.40); and 5) poor control of some symptoms (2.83±0.96). The frequencies and severities of the various dilemmas reported by the health care givers were not significantly influenced by their age, sex, religion, or professional experience. The results of this study suggest that it is important to accumulate evidence from palliative care studies and educate professionals to make decisions on the basis of the framework of ethical principles. Developing better solutions creatively and establishing proper guidelines will be helpful for improving the quality of care.