中風合併低血鈉病人的居家照護經驗：死亡個案報告

The Death of a Home Care Patient with Stroke and Hyponatremia due to Chronic Hepatitis C Related Hepatocellular Carcinoma: A Case Report

台灣即將邁入高齡社會，老年失能人口日漸增多，對於此類病人的居家醫療照護更顯重要。居家訪視的醫師主要由家庭醫學科醫師擔任，應該盡責地提供可近、連續、周全、以病人為中心的評估與照護。本文分享一位中風長期臥床的居家照護病人，有慢性低血鈉，固定在腎臟科門診追蹤。居家醫療照護也在評估後給予適量鹽分及避免水量過多，之後低血鈉沒有惡化也沒有持續更改善。而病人最後死於肝細胞癌，回顧病史時發現曾於健康檢查被驗出anti-HCV陽性，但後續沒有被規則追蹤及檢查。目前並沒有針對功能狀態不佳且長期臥床病人適用的慢性肝炎追蹤指引。本文藉由文獻探討此病人低血鈉的病因分析、老年人常見低血鈉的原因、肝細胞癌與低血鈉的關係、慢性肝炎病人追蹤的準則以及醫學倫理的分析，希望提供家庭醫師在進行居家醫療照護時，如何給予這類病人適當的全人照護做參考。

As Taiwan is becoming an aged society, the number of its senior citizens with disability has been on a steady rise, rendering home care an increasingly crucial issue. Home visit doctors in Taiwan are mainly family physicians who are expected to provide accessible, continuous, comprehensive, and patient-centered assessment and care. This case report presents a 93-year-old bedridden woman, a home care recipient, with a history of stroke. She had chronic hyponatremia and was regularly followed at a nephrology clinic. The home care family physicians, after assessment, prescribed an increase of dietary salt and water restriction; her hyponatremia, however, showed neither improvement nor deterioration. The patient finally died of hepatocellular carcinoma. Post-mortem review of her medical records noted a positive anti-HCV test result at a previous health examination, yet no regular follow-up examination was provided. The differential diagnosis of hyponatremia in this patient, the common etiology of hyponatremia in the elderly, the association between hepatocellular carcinoma and hyponatremia, the protocols of follow-up for chronic viral hepatitis, and an analysis of medical ethics are discussed by literature review. The goal of this case report is to help family physicians provide appropriate holistic care for home health care patients.