末期病人面臨預立醫囑、生前預囑之現況及與生命自決之倫理議題

Ethical Issues in the Practice of Advance Directives, Living Wills, and Self-Determination in End of Life Care

我國於2000年通過安寧緩和醫療條例之立法，該條例為尊重不可治癒末期病人之醫療意願及權益的保障，同時也協助醫護人員在面對末期病人的臨終照顧時，有可遵循的醫療照護法則。生命自決是人性尊嚴的核心內涵，病人對所將接受的醫療照護，保有自主與自決的權利。透過「預立醫囑(advance directives)」的簽署，得以讓個人在意識清醒、有行為能力時，為自己未來所希望獲得的醫療處置作一個預先的指示或說明的文件，此文件內容包含書面立妥「生前預囑(living will)」與「預立醫療委任代理人(durable power of attorney for health care)」兩份文件之簽署。在預立醫囑的決策過程中，家屬是很重要的影響因素，預立醫囑的討論與書面文件的簽署，經常是在病人病情嚴重、接近臨終時，而且多數經由家屬代理同意，此外，病情告知的困境、不予與撤除的掙扎、認知與執行上不一致等，皆使得醫護人員在與病人和家屬討論預立醫囑時更顯得困難，無法充分尊重病人之生命自決權。本文透過對預立醫囑的探討，來澄清並理解病人、家屬與醫護團隊彼此的經驗，期望能達成醫護人員間對預立醫囑的共識，提昇終末病人自主權益，尊重其對生命權與人性尊嚴之價值，及親屬的照護與支持。

The Hospice-Palliative Care Act, enacted in Taiwan in 2000, was designed to respect the end of life medical wishes of patients with incurable illnesses, safeguard the rights of these patients, and provide clinical guidelines for healthcare workers responsible to provide end of life care. Self-determination is a core element of human dignity. Advance directive documents include a living will, and durable power of attorney for healthcare. This article reviews current issues and ethical dilemmas with regard to advance directives. Patients, family members, and clinicians may require better education on the Hospice-Palliative Care Act in order to respect more appropriately patient end of life medical care wishes.