應否撤除氣管內插管？：《安寧緩和醫療條例》修正前後之倫理與法律議題探討   全文下載

To Extubate or Not to Extubate? -Ethical and Legal Issues Around the Amendment of Hospice Palliative Care Act of Taiwan in Jan 2011

本文藉由一位癌症末期病人撤除氣管內插管之過程，探討當病人自主權與法律問題衝突時，產生的倫理與法律困境。此個案發生於《安寧緩和醫療條例》修正案通過前，最後病人家屬辦理「因疾病末期出院」，並在返家後請民間救護車公司之護理師拔管，安寧緩和醫療團隊之醫師則從旁協助給予緩和藥物，確保病人拔管過程病人之舒適性，因而兼顧了病人最佳利益與自主。本文也探討病危病人由家屬帶回家自行拔管可能的倫理與法律爭議。
在2011年1月26日，《安寧緩和醫療條例》修正案由總統公布施行，在配偶與直系親屬一致同意，並通過醫院之倫理委員會審查之前提下，終於給了未及於心肺復甦術前簽署「選擇安寧緩和醫療意願書」或預立醫療委任代理人之昏迷末期病人撤除心肺復甦術之法源依據。本文也探討修法之後，執行上可能之困難。由於法律較缺乏彈性，本文之結論為繼續安寧緩和醫療觀念之推廣，鼓勵國人預立未來照顧計畫，或預立醫療委任代理人，才能保障自己的臨終醫療自主權。

On 26 Jan 2011, the amendment of hospice palliative care act of Taiwan was issued, which allows unconscious terminally ill patients to have the rights to get ventilators and other life-supporting systems withdrawn with the consent of their families and the approval of ethics committee of the hospital. We have presented a female patient with terminal breast cancer, who received tracheal intubation due to intractable seizure. She never regained consciousness and developed liver failure after the intubation. To protect her best interest and respect for autonomy, compassionate extubation was done for the poor prognosis after discussion with her families. The patient died peacefully at home with the accompany of her families in stead of being hospitalized at the intensive care unit.
Before the amendment of hospice palliative care act of Taiwan, the con.icts between patient's autonomy and law were often because it lacked the law origin basis to withdraw ventilators and other life-supporting systems on a unconscious terminal ill patient without a advance care planning or a medical surrogate even if medical futility was evident. The ethical and legal concerns before and after the amendment were explored in the article. The possible dif.culties in spite of the amendment were also discussed. The main suggestions of the article were to encourage Taiwanese to issue the advance care planning and medical surrogate to diminish the ethical and legal dilemma.