以關係自主談重症末期病人決策自主權－－案例討論

The Decision-Making Autonomy of Critical Patients at End of Life From the Perspective of Relational Autonomy: A Case Discussion

尊重自主是醫學倫理的重要原則，近來學者認為社會中人與人間必然存在關係，透過這些關係會形塑出個人的自我及決策能力，而衍伸關係自主。故關係自主是個人在考量自身的社會文化背景，在醫療決策情境中透過不斷與醫療團隊、家庭和其他重要關係的互動、傳達訊息，在相互信任、關懷與真誠合作的關係中，所培養出的自主決策能力。本文以案例討論透過關係自主的概念，討論重症末期病人決策自主權。當病人意識清楚可做決策，醫療專業人員須提供一個信任、開放且關懷的溝通環境讓所有關係人共同互動及討論，以幫助病人行使自主權。若病人失去意識無法做出決策，此時可以透過預立醫囑來尊重病人意願，若未簽立任何意願書，才由其法定代理人，依照病人之前的意願和價值觀來尊重病人自主權。然而，由於重症病人疾病預後不易預測，且民眾與醫療專業人員對預立醫囑知識普遍不足，加上習俗忌諱談論死亡，導致預立醫囑仍不普及。期許本文能讓醫療專業人員了解如何在醫療決策情境中落實重症末期病人關係自主的展現。

Respect for autonomy is an important principle of medical ethics. Individuals exist within socially embedded networks that include many people, and develop their sense of self and decision-making capacity through network relationships. The concept of relational autonomy has been proposed as a feasible alternative to individual autonomy. Within the framework of relational autonomy, an individual builds up their decision-making capacities through continuous interaction, delivering information and knowledge to the medical team, family, and other important relations while considering their own social and cultural backgrounds within the contexts of trust, caring, and sincere collaboration. The authors of this study integrated the concept of relational autonomy and analyzed the decision-making autonomy of critical patients. When a patient has decision-making capacity, health professionals must provide a trusting, open, and caring communication environment for all important stakeholders to interact, discuss, and assist patients to demonstrate their autonomy. If a patient is unconscious or unable to make decisions, their wishes need to be respected. However, if this patient has not signed a document of intent, the legal representative must respect patient autonomy in accordance with their previous wishes and values. However, the disease prognosis is not easy to predict, the public and health professionals lack knowledge of advance directives, and it is considered taboo to talk about death. Advance directives remain unpopular. Therefore, we hope this article may assist health professionals to demonstrate patient relational autonomy in medical decision situations.