運用倫理分析於老年腎病末期病人終止血液透析之共享決策經驗

老年腎病末期病人苦於衰弱及多重共病與併發症導致高死亡率，疾病的不可逆性與病程進展軌跡起伏不定攸關生命末期生活品質，並突顯及早了解老年人對末期醫療想法與期待的重要。本文運用倫理分析協助一位老年腎病末期病人及其家屬，在面對不確定性的疾病軌跡及是否要終止透析治療之兩難過程中，透過醫療共享決策達成最佳可行的治療選擇。根據整體性評估分析，病人的主要健康相關問題有維持或終止血液透析與否之醫療決策兩難、瞭解痛與苦難。醫療照護團隊以症狀控制和舒適護理為優先，與病人及其家屬建立信任與親善關係，採Josen、Siegler與Winslade之倫理四面向（4-boxes）整體分析權衡利弊得失，幫助病人表達餘生期待，並考量影響決策背後之苦，引導病人察覺自我與他人關係之連結，從對家人的愛與支持中找回自我的價值與生命意義，並彈性依照不同病程階段，以「需求」為導向提供符合病人最大福祉之持續性照護計畫，達成以家庭為中心的醫療共享決策，提升老年末期腎病病人之整體生活品質。 Elderly patients with end stage renal disease (ESRD) frequently suffer from frailty, multiple comorbidities, and complications that greatly increase the mortality rate for this population. The irreversibility and variability of ESRD directly affect quality of life, which highlights the importance of gaining an early understanding of the preferences and expectations of these patients with regard to end-of-life care. This article describes a nursing experience that used ethical analysis to help an elderly ESRD patient and the dilemma faced by his family as to whether to sustain or withdraw hemodialysis. This article examines the uncertain trajectories of this disease and how to use shared decision making with the patient and his/her family to make the best decisions. A comprehensive assessment was conducted to identify the major health-related problems, to elicit the dilemmas faced in making the decision to sustain or end hemodialysis, and to understand the pain and suffering of the patient. Symptom control and comfort were identified as the most important goals of the patient, followed by building trust and rapport with his family. An analysis of the pros and cons of treatment was conducted using the 4-box ethical analysis developed by Josen, Siegler, and Winslade. The shared decision-making process was applied to help the patient express his expectations for his end-of-life care. While the health professionals considered that pain and suffering may influence the patient's decision, the patient found his connection between himself and others, self-value, and meaning of life through family love and support. A needs-based, flexible approach was adopted that established a continuous-care plan that was designed to provide the best care for the patient under a variety of possible scenarios while involving the family, which created a family-centered decision-making process that improved the quality of life of the elderly ESRD patient.