運用共享決策於一位腎癌併皮下轉移病人之照護經驗

Using Shared Decision-Making on a Patient with Renal Cell Carcinoma and Subcutaneous Metastasis: A Care Experience

當病人處於積極接受治療及期待出院返家的狀態，但醫療團隊評估手術或放射線等任何治療，皆很難使其生命可有意義的延續，此時要如實告知病人病況及提出撤除維生醫療，對提供資訊的醫療同仁是種艱深的考驗。本文描述一位腎癌合併皮下轉移的病人，出現下肢水腫及皮下腫瘤疼痛影響血液透析成效，住院期間由期待出院轉折到病況急速惡化，在生命延續與生活品質難以兼顧狀況下，病人面對疾病開始產生死亡焦慮。筆者運用共享決策概念，引導個案提出自己的期望，藉由溝通討論，提供首要醫療照護選項及抉擇撤除血液透析治療，並依病人疾病進展，善用不同精油，穩定病人情緒及緩解疼痛，最終，協助其完成臨終準備，並及時與孩子道別、與父母兄姊道謝，讓病人獲得善終。

When a patient aggressively receives treatment and looks forward to returning home, the prolonging of meaningful life is difficult, even with medical treatment. It is typically very challenging at this juncture for the members of the medical team to fully disclose to the patient the true extent of his / her condition and to recommend the withdrawal of life-support medical treatment. This article describes a nursing care experience with a renal cell carcinoma patient with subcutaneous metastasis. Her pain was induced by an edema and subcutaneous tumor in her lower limbs, which diminished the effectiveness of hemodialysis. During hospitalization, the mood of the patient shifted from looking forward to recovery to facing a rapidly worsening health status. Achieving a balance between fighting the disease and sustaining patient quality of life became increasingly difficult, and the patient began experiencing anxiety about dying. We use the belief of shared decision-making to guide the case in a discussion of her expectations during which primary medical care options and her choice to withdraw from hemodialysis treatment were explained. Essential oils, selected for appropriateness with her current disease stage, were used to stabilize her mood and relieve pain. In the end, we helped the patient to complete her pre-death preparations and to say goodbye to her children, parents, and siblings. As a result, the patient experienced a good death.