安寧療護臨床決策的醫學倫理

Ethics in Clinical Decision Making in Palliative Care

安寧療護的內在目標在使病患獲得身心靈的整體安適，因此其介入的照護目標必須符合人性，充分理解罹病及治療過程對每位病患的意義，站在以病患觀點去追求病患整體上的好處。唯有在臨床決策過程中，不斷融合倫理道德的觀點思維考量，才能達成上述目標，獲致病患的整體舒適及安寧。疾病的過程常受許多因素影響，尤其在安寧療護領域，不論我們做出任何決策，都僅只有影響後果的單一因素而已，醫療人員無法針對每一件事情的後果負擔倫理上的責任。事實上，決策的過程才是重要焦點，也是所有專業醫療照護人員在醫學倫理道德上應該負責的地方。針對嚴重傷病末期病患是否提供「延命治療」，必須視各種特殊情況，藉由利益與風險負擔的計算，提供給有自主權決定的病患，根據個人價值觀來作理性的考慮及抉擇。當病患無自主能力時，則須根據病患家屬或醫療委任代理人所提供的病患價值觀及好惡，在考慮利害得失之後提供治療計畫。總之，不管是繼續或停止治療，醫療團隊應時時審視並反省決策過程，並在提供各種治療建議之前，積極充實自己具備專業常識及經驗，除需了解在各種不同特定情況下，不同症狀包對含心理及社會靈性問題的處理方法，並應訓練自己擁有「因考慮對病患的整體益處，而不提供治療建議」的臨床智慧。

The intrinsic aim of palliative care, as part of health care, is the promotion of a medical good related to physical or mental illness. This professional treatment must be humane and show full appreciation of the disease or disorder, the suffering and treatment of the particular patient, and the place of treatment in the patients' conception of his total good. The ethical concepts introduced are integral to the pursuit of these aims and the controlling virtue is that of practical wisdom. Only the exercise of practical wisdom can ensure that the caregiver's conception of the patient's medical good may just be left in peace. The moral quality of a clinical decision is dependent on the process of the decision and not only on the outcome. We are also accountable and responsible for the way our decisions may reach. In palliative care, outcomes are multifactorial and unpredicatable. Therefore we are usually only partially responsible in a causal sense for the outcome, and are blameworthy or praiseworthy in respect to the outcome only to the extent that our decision of itself influenced the outcome. The rightness or wrongness of life-prolonging and life-sustaining treatments in palliative care depends on the particular clinical circumstances in which they are considered. Treatment options are selected by caregivers on the basis of the benefits to burdens/risks calculus. They are then offered to autonomous patients, or considered by caregivers and relatives on behalf of non-autonomous patients. Since the outcome of treatment is always uncertain because of the unpredictability of the disease course and the uncertainties of the benefits to burdens/risks calculus, treatments should be reviewed regularly and caregivers should always remain willing to modify treatment accordingly. Caregivers should not intend to cause overall harm to patients in the interests of the relatives, but it is sometimes morally justifiable to compromise the good of one patient in the interests of others.