「安寧緩和醫療條例」實施後臨床困境初探－醫師的角度

南華大學機構典藏系統 > 人文學院 > 生死學系(生死學系碩士班,哲學與生命教育碩士班) > 博碩士論文-生死學系碩士班 > Item 987654321/21511

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题名:	「安寧緩和醫療條例」實施後臨床困境初探－醫師的角度
其它题名:	The Dilemma after the Clinical Practice of 「The Nature Death Act」-- the Physician's Role
作者:	林惠貞 Lin, Hai-jane
貢獻者:	生死學研究所孔令信 Ling-xin Kung
关键词:	緩和醫學;安寧療護;安寧緩和醫療條例 Palliative care;Palliative medicine
日期:	2004
上传时间:	2015-06-16 14:23:39 (UTC+8)
摘要:	由於科技與急救技術的進步，現代醫學似乎有延長生命的可能。相對地，醫師、病人及家屬在病人病情末期時所面對的考慮與抉擇，也就更加複雜與困難。無論站在醫師、病人或家屬的立場，都有難以兩全的困境。在缺乏適當的法律依據時，便會產生許多紛爭。臨床上，醫療人員常會面臨明知病人已回天乏術，卻還要不顧病人生命尊嚴而急救到底；或是擔心家屬無法諒解不做急救而被控訴，徘徊在良心與法律兩難的煎熬。而末期病人與家屬在危急時刻，內心徬徨與痛苦，更是不知如何適從。　　　所幸在立法委員及民間團體努力推動下，終於在民國89年5月23日立法院三讀通過「安寧緩和醫療條例」，6月7日由總統公布，正式施行。條例的制定是為了尊重不可治癒末期病人之醫療意願及保障其權益，同時也協助醫療人員在面對末期病人的臨終照顧時，有可遵循的法則。所以此條例不僅尊重病患自然死的權利，也解決了部分臨床上的困境，同時此一條例因著尊重「自然死」，而避開了「安樂死」的困境。　　　然而此條例立意雖好，但不管是臺灣醫界或法界，甚至病人及家屬，皆未完全承認此條例對病人自主權的概念與實施。而且臨床應用上也有許多窒礙難行之處。而由於醫師是醫療團隊的主幹，經常在醫療機構中扮演領導者的角色。所以在「安寧緩和醫療條例」實施兩三週年後，研究者希望藉由醫師的角度，透過相關議題的探討，達到以下之目的：一、了解臨床醫師對「安寧緩和醫療條例」的認知。二、了解臨床醫師對「安寧緩和醫療條例」實際運作的模式。三、了解臨床醫師對「安寧緩和醫療條例」實施後的影響與限制。四、針對「安寧緩和醫療條例」臨床實施狀況提出改善方向與因應對策。　　　由於「安寧緩和條例」實施三週年，目前只有數篇量性研究，並無深入探討臨床醫師真正面臨的臨床狀況及情緒反應。所以本研究以安寧療護團隊醫師與急診室醫師為主要對象，進行質性深度訪談。並透過預試訪談，針對訪談的題目及對象的選取作修正，同時以立意選樣及滾雪球方式取樣，樣本來源為服務於台北市、台北縣及花蓮等一級教學醫院的安寧緩和專科醫師與急診室醫師共八位。希望經由訪談過程，能整理歸納出醫師們真正的看法與臨床狀況，期望透過探索的過程，使得以尊重生命、維護臨終病患生活品質為信念的「安寧緩和醫療條例」，能更廣泛落實在醫療體系中，並作為未來修訂政策的參考依據。　　　根據研究結果發現，造成醫師在臨床上條例實施時窒礙難行的主要原因包括，一、條例的名稱與內容，二、病情告知，三、倫理上的抉擇，四、醫療行政的支持等。而探討其現象後的社會意義，除了條例本身沒有辦法制定得很清楚外，還包括醫師科別不同、病人自主與知情同意及家族主義與醫病關係。　　　根據結果分析安寧專科醫師與急診室醫師，在臨床上遇到的困境與所選擇的醫療決策，及影響決策背後的因素與差異性。經研究者深入訪談資料分析出三個主要議題，一、條例的制定與執行，二、醫療糾紛與醫療行為，三、醫療行政與醫療政策等。因此本研究在建議的部分，針對以上的問題與困境，依臨床實務與政策面，一一提出適當的建言。　　　由於「安寧緩和醫療條例」是國內首度立法走在社會風俗之先，在社會大眾尚未明白何謂「安寧緩和醫療」之前，在家屬都還不知尊重「病人自主權」之前，所以醫療團隊在實際執行面遇到許多困難，這有待醫療團隊及家屬建立共識並重新修改或訂正的空間，希望本研究能彙集各臨床專業的意見，提供更具體可行的方案，建立本土化的機制，落實「安寧緩和醫療條例」的精神與內涵，並尊重末期病人最後的尊嚴與權利，才是真正尊重人性與人道關懷！　　As a result of technical and the first aid technology progress, the modern medicine has as if lengthens the life the possibility. Relatively, doctor, patient and family member when patient condition last stage faces consideration and choice, also more complex and is difficult. Regardless of stands in doctor, the patient or family member's standpoint, all has the difficult position which is satisfactory to both sides with difficulty. When lacks the suitable legal basis, then can have the ornamental hairpin h dispute. On clinical, the medical officer regular meeting faced with knows perfectly well the patient already great power deficiency technique, actually also or gives a thought to the patient life dignity to administer first aid; Perhaps worried the family member is unable to forgive does not make the first aid to complain, paces back and forth the suffering which is in a dilemma in the conscience and the law. But the last stage patient and the family member in the critical time, the innermost feelings dilemma with the pain, did not know how follows.　　　Fortunately under legislation committee member and the folk association diligently impetus, finally three reads in 2,000 in May 23 Hitachi court passes ＂The Nature Death Act＂, on June 7 announces by president, official execution. The rule formulation is for respect cannot cure medical service of wish the last stage patient and safeguard its rights and interests, simultaneously also assists the medical officer when faces the last stage patient just before the end the attendance, has principle which may follow. Therefore this rule not only respect sickness naturally dies right, also has solved the partial clinical on difficult position, simultaneously this rule because the respect ＂ Nature death＂, but has avoided ＂Euthanasia＂ difficult position.　　　However this rule decides although is good, but no matter is the Taiwan medicine or the legal community, even the patient and the family member, all not completely acknowledges this rule to the patient right to independence concept and the implementation. Moreover in the clinical practice also has ornamental hairpin h to obstruct difficulty the line place. But because doctor is the medical team's branch, frequently acts leader's role in the medical establishment. Therefore after ＂The Nature Death Act＂ to implement for two third anniversary, the researcher below hoped the affiliation by doctor's angle, the penetration correlation subject discussion, achieves the goal:1. To understanding clinician to ＂ The Nature Death Act＂ the cognition. 2. To understanding clinician to ＂ The Nature Death Act ＂ the actual operation pattern. 3. To understanding clinician after ＂ The Nature Death Act ＂ the implementation influence and the limit.4. Aims at ＂ The Nature Death Act ＂ the clinical implementation condition to propose the improvement direction and in accordance to the countermeasure.　　　Because ＂ The Nature Death Act ＂ to implement the third anniversary, at present only has several quantities research, and not thorough discussion clinician truly faces clinical condition and mood response. Therefore this research take peacefully palliative care team doctor and emergency room doctor as the main object, carries on nature depth interview. And penetration pretesting interview, makes the revision in interview the topic and the object selection, simultaneously take decides the sampling and rolls the snowball way sample, the sample originates as serves Taipei, the Taipei county and Hualian and so on level of teaching hospitals peacefully relaxes faculty doctor and emergency room doctor altogether eight. The hope by way of interview the process, can reorganize induces doctors the true view and the clinical condition, expected the penetration exploration the process, enables take to respect the life, the maintenance just before the end sickness life quality ＂ The Nature Death Act ＂ as the faith, will be able a more widespread realization in the medical system, and revises the policy as the future the reference.　　　Discovered according to the findings, creates doctor when on the clinical rule implementation obstructs difficulty a line of main reason to include：1. the rule name and the content.2. the condition informs.3. in ethics choice.4. medical administration support .　　　But after discusses its phenomenon the social significance, does not have the means besides rule itself to formulate very much clearly, but also includes doctor the branch not to be different, the patient independently with knows the circumstances of the matter the agreement and the clannism with treats an illness to relate. According to result analysis peaceful faculty doctor and emergency room doctor, in the difficult position which on clinical meets with the medical decision-making which chooses, and behind influence decision-making factor and difference. Analyzes three main subjects after the researcher thorough interview material：1. Rule formulation and execution.2. Medical dispute and medical behavior.3. Medical administration and medical policy and so on.　　　Therefore this research in the suggestion part, in view of the above question and the difficult position, according to the clinical solid service and the policy surface, 11 proposes suitable stating opinion.　　　Because ＂ The Nature Death Act ＂ is the domestic first legislation walks in the social custom first, in the social populace not yet understood what ＂palliative medicine＂ before, all does not know the respect in the family members ＂the patient right to independence＂ before, therefore the medical team meets ornamental hairpin h in the actual execution surface to be difficult, this waits for the medical team and the family member establishes the mutual recognition and rerevises or the revising space, hoped this research can collect each clinical specialized opinion, provides a more concrete feasible plan, establishes the localization the mechanism, the realization ＂peacefully relaxes the medical rule＂ the spirit and the connotation, and respect last stage patient's final dignity and right, Is the true respect human nature and the humanity concern!
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