運用跨團隊合作協助一位口腔癌末期呼吸器依賴個案返家之照護經驗

A Nursing Experience of Cross-Team Collaboration in Assisting a Terminal Oral Cancer Patient Dependent on Mechanical Ventilation to Return Home

本文描述一位運用跨團隊合作，協助一位口腔癌末期呼吸器依賴個案成功下轉居家呼吸之照護經驗。護理期間自2023／6／25~2023／8／2，筆者經由直接照顧、觀察、參閱病歷、會談、筆談、身體評估等方式蒐集資料，運用生理、心理、社會及靈性四大層面進行整體性評估。因文章篇幅限制，以影響個案及家庭身心健康問題及疾病變化衝擊：慢性疼痛、心靈困擾、照顧者角色緊張等健康問題探討。運用癌症疼痛控制策略及非藥物治療，分散注意力達到緩解、控制疼痛；鼓勵個案表達感受，適時給予陪伴及關心，個案終能以正向態度來面對疾病，減少心靈困擾；運用跨團隊合作模式結合呼吸治療師、出院準備服務及居家安寧療護，提供個案與家庭整體性照護知識與技巧，確認學習成效。最終，個案8／2成功轉銜居家呼吸照護，成功返家。由於全民健康保險居家醫療照護整合計畫中服務資格規範限制，呼吸照護機構鮮少合併安寧療護服務，資源有限情況影響臨床作業安排，建議應整合雲嘉地區呼吸照護及安寧療護等居家醫療照護服務機構清冊，提供個案及家屬多元服務外，更建議掌握開啟家庭會議時間，討論並提供居家呼吸照護轉銜資源等醫療照護相關重要議題。

This article reports a nursing experience of cross-team collaboration assisting a terminal oral cancer patient dependent on mechanical ventilation to return home care. From June 25 to August 2, 2023, holistic assessment identified chronic pain, psychological distress, and caregiver role strain as major issues. Interventions included cancer pain management, non-pharmacological therapies, and psychological support to foster a positive attitude. Collaboration with respiratory therapists, discharge planning, and home palliative care teams provided education and skills training, enabling successful transition to home respiratory care. Due to National Health Insurance limitations, integration of respiratory and palliative services is insufficient; hospitals are advised to compile regional resources and conduct early family meetings to improve home care continuity.