末期醫療照顧替代決定之有效性：文獻回顧

Validity of substituted judgment in terminal care: a literature review

目的：保障病人自主決定是重要醫療品質，由最近親屬替代病人決定末期醫療策略，反而可能違反其自主意願，並且發生猶疑、爭執、要求不當醫療等情形。

方法：本文目的，是回顧由2009年1月至2019年6月之文獻，分析病人和親屬對末期醫療照顧之差異。另外，比較本國與美國紐約州和加州相關法律，瞭解替代決定的人選和順序，及帶來的爭議之應對策略。

結果：約三成病人會隨時改變醫療策略，多數病人希望由家人共同決定其末期醫療照顧；若單獨決定時，配偶和孩子之比例相當。親屬預測病人醫療意願之整體準確性只有56.7%，且會擅自改變內容。參照美國，我國法律中替代決定人選和順序類似，但是欠缺最近親屬指定代理人、司法指定監護人和醫療機構拒絕不 當/無效醫療的權利。

結論：病人對本人的醫療決定呈流動性，常常變動，而最近親屬之替代決定並非完全接近病人醫療意願。 解決親屬因替代決定的衍生爭議，應適當增訂親屬、司法和醫療機關的代理、參與和拒絕之權利或義務。

 

Objective: The protection of patient autonomy is an important parameter of healthcare quality.

Substituted judgment by patients’ family members may violate patient autonomy, cause hesitation and conflict, and result in incorrect decisions regarding inappropriate medical procedures.

Methods: This study reviewed the literature on the differences between medical decisions made by terminally ill patients and their family members between January 2009 and June 2019 and compared the legal policies on medical decision-making and dispute resolution strategies between the states of New York and California in the United States and Taiwan.

Results: Approximately 30% of patients changed their decisions during their course of disease. Most patients expected their spouses and children to make decisions together. Spouses and children were equally often chosen as sole decision makers. The families frequently modified patient decisions, and their accuracy rate in predicting patient decisions was only 56.7%. Unlike that in the United States, Taiwan’ s legislature does not address substituted judgment by family, legal guardianship, or the right of refusal of futile or substandard medical care.

Conclusions: Medical decisions are dynamic. Substituted judgment by family poorly predicts terminal patient decisions. To solve disputes arising from substituted judgement, the relevant rights and duties of family and judiciary and medical institutions require adjustment.