運用醫病共享決策於氣切手術抉擇衝突

Application of Shared Decision Making for Tracheostomy in an ICU Patient with Decision Conflict

加護病房病人常因急性呼吸衰竭或上呼吸道狹窄原因緊急放置氣管插管，大部分的病人可在短期內訓練脫離呼吸器成功，進而移除氣管內管。但依據國外的文獻研究指出仍有高達5－13％病人會使用呼吸器大於21天。這些須依賴人工氣道維生的病人，通常重症醫師會建議病人與家屬接受氣管造口術，以利後續照護及避免長時間放置氣管內管所導致相關的併發症。但對於病人與家屬而言，面對重大醫療處置的陌生及迷思，常導致決策者處於被動及依賴醫師的角色，而陷入抉擇衝突的情境發生。本案例為一名67歲男性因慢性呼吸衰竭面對是否執行「氣管造口術」所產生之抉擇衝突。照護過程運用「醫病共享決策」模式，以傾聽為出發點，系統性的評估病人或家屬是否具備疾病、檢查或治療相關的知識，並使用問卷表單來探索病人本身的價值觀，找出最適合自己的醫療治療決策，達至醫病溝通雙贏的局面。 Acute respiratory failure or upper airway stenosis related to endotracheal intubation in intensive care unit.Most of patients canwean from mechanical ventilation in a short time.However, literature review indicated that5-13%patients receivedmechanical ventilation for more than 21 days. For patients, relying on endotracheal tubewith mechanical ventilation support, tracheostomy will be suggested by physiciansin order to avoid complications associatedendotracheal tubes placement and to benefit the long-term care.However, lack of knowledge for medical treatment from patients and families is a major problem to make a decision for the main decision maker which resulting over-relying on physician’s suggestions. The situations that fall into conflict of choices.We reported a 67-year-old malewith chronic respiratory failure who faced decisional conflict for tracheostomy in MICU.We conducted shared decision making with listening and systemic evaluation to patient and families for ability to understand the information about disease. We also used questionnaire to investigate the own personal value of patient and find out the most appropriate medical decision for the patient.