臺灣博碩士論文加值系統

背景: 在華人文化中，「家」是代表著一個人一生的成果，而落葉歸根則是生命價值的歸屬。然而，在現今的醫療技術日新月異中，面對疾病的發生，家屬為了能延續病人的生命、醫療期望創造「人定勝天」的優越，在病人面臨生命末期之中，無不努力的提供過度的醫療介入及醫療機構化的狀態。鑑於現代人在醫院臨終時所面臨使用過多不必要的醫療措施、缺乏心理社會層面的照顧、缺乏家庭安全感的支持、無法尊重病人的個別性，因此，安寧居家療護提供居家醫療，陪伴病人、家屬面對生命末期之善終準備歷程。

目的：本研究採行動研究法以安寧居家照護收案病人為主體，探討來自於安寧居家收案病人於安寧療護照護過程中所需要的生理、社會心理、靈性上的需求，以提升護理人員臨床照護，提升護理照護品質。

方法：本研究採用行動研究方法進行，立意取樣針對南部某區域教學醫院安寧居家收案，透過研究者參與式觀察及病歷回顧、質性問卷訪談，了解病人面臨瀕死生理症狀及社會心理、靈性、喪親家數哀傷追蹤上問題，制訂末期病人善終準備之流程，採取行動並評值成效。

結果：透過70 例病歷回顧了解安寧居家收案死亡病人於臨終時的生理症狀有生命徵象變化、張口呼吸、虛弱、雙眼上吊、大小便失禁、發紺；社會心理、靈性照護需求著重臨死覺知上的需求。行動研究過程中以瀕死病人症狀進行評估，再對應安寧護理師之困難評估之瀕死症狀及喪親家屬哀傷追蹤，以完成善終準備流程、瀕死症狀評估流程及喪親家屬遺族追蹤流程。

結論：運用行動研究迴圈中研究者亦為執行者，進行安寧居家收案瀕死病人之善終準備評估與執行，能更加清楚了解臨床末期病人的需求及家屬的哀傷評估，更進一步提供更適切的照顧計畫與善終準備。

Background: In the Chinese culture, "home" is the result of a person's life, and getting home is the attribution of the value of life. However, medical technology advanced greatly, family try to extend the lives of patients. In the end of patient's life, family and physicians do their best to provide excessive medical intervention. They tend to keep patients in hospital for advanced medical care. In view of excessive use of unnecessary medical measures in terminal care, we should stress the importance of the lack of psychosocial care, family support, and indivisualized management.
Objective: This study aimed to investigate the physiological, psychosocial and spiritual needs of terminally ill patients who receive hospice home care by the action research method. The purpose is to improve the quality of clinical nursing care.

Methods: This study was conducted by the action research method in a metropolitan teaching hospital in Southern Taiwan to investigate terminally ill patients who receive hospice home care. By means of participating observation, chart review, and qualitative research questionnaires, we learned terminally ill patients' physiological, psychosocial and spiritual problems and the grief of bereaved family. We formulate a algorithm improve the preparation of a good death for terminally ill patients. Then we take action and evaluate the effects.

Results: We reviewed medical records of 70 patients who receive hospice home care to understand pre-dying symptoms, incluing change of vital signs, breath with mouth open, weakness, upward gaze, incontinence, cyanosis.
Psychosocial and spiritual care focus on nearing death awareness. During the course of action research, we evaluated the symptoms of the pre-dying patients, and then integrate the symptoms difficult to access by hospice nurse and follow-up of the bereaved family.

Conclusion: In the action research circle, the researcher also carry out evaluation and implementation of the preparation of a good death for pre-dying patients who receive hospice home care. The resercher can
understand better the needs of terminally ill patients and the grief of bereaved family. Furthermore, we can provide more appropriate care planning and preparation for a good death.

目 錄
致謝 -------------------------------------------------------------------------- ⅰ
中文摘要 -------------------------------------------------------------------------- ⅲ
英文摘要 -------------------------------------------------------------------------- ⅴ
目錄 -------------------------------------------------------------------------- ⅶ
圖目錄 -------------------------------------------------------------------------- ⅸ
第一章 緒論-------------------------------------------------------------------- 1
第一節 研究動機與背景----------------------------------------------------- 1
第二節 研究問題-------------------------------------------------------------- 2
第三節 研究目的-------------------------------------------------------------- 2
第四章 名詞定義-------------------------------------------------------------- 3
第二章 文獻探討-------------------------------------------------------------- 5
第一節 安寧療護發展 ----------------------------------------------------- 5
一 台灣安寧療護之歷程----------------------------------------------- 5
二 台灣的安寧療護模式----------------------------------------------- 6
三 安寧居家現況與困境----------------------------------------------- 7
第二節 臨終病人居家照護需求 ------------------------------------------- 9
一 瀕死症狀與照護------------------------------------------------------ 10
二 居家後事準備--------------------------------------------------------- 15
三 遺體護理-------------------------------------------------------------- 16
四 死診開立-------------------------------------------------------------- 18
第三節 家屬的哀傷照護需求----------------------------------------------- 20
第三章 研究方法-------------------------------------------------------------- 20
第一節 行動研究法---------------------------------------------------------- 21
第二節 研究方法選擇------------------------------------------------------- 23
第三節 研究設計------------------------------------------------------------- 24
第四節 研究參與者與地點-------------------------------------------------- 28
第五節 資料收集方式-------------------------------------------------------- 28
第六節 資料分析-------------------------------------------------------------- 30
第七章 倫理考量-------------------------------------------------------------- 35
第四章 研究結果-------------------------------------------------------------- 37
第一節 研究對象描述-------------------------------------------------------- 37
第二節 善終準備對新進護理師的挑戰----------------------------------- 39
第三節 安寧居家瀕死照護優先順序-------------------------------------- 47
第四節 安寧居家死亡病歷分析-------------------------------------------- 53
第五章 討論與限制----------------------------------------------------------- 67
第一節 研究優勢-------------------------------------------------------------- 67
第二節 研究限制------------------------------------------------------------- 68
第三節 研究應用------------------------------------------------------------- 68
第六章 結論與建議---------------------------------------------------------- 71
第一節 結論------------------------------------------------------------------- 71
第二節 建議------------------------------------------------------------------- 72
參考文獻 ------------------------------------------------------------------------- 73
附錄一 ------------------------------------------------------------------------- 80
附錄二 ------------------------------------------------------------------------- 102
附錄三 ------------------------------------------------------------------------- 104
附錄四 ------------------------------------------------------------------------- 105

圖 目 錄
圖一 研究架構圖------------------------------------------------------------------ 24
圖二 資料收集流程--------------------------------------------------------------- 29
圖三 安寧團隊護理師基本資料------------------------------------------------ 38
圖四 喪親家屬基本資料--------------------------------------------------------- 38
圖五 DNR簽署與安寧居家收案------------------------------------------------- 45
圖六 瀕死生理症狀--------------------------------------------------------------- 47
圖七 瀕死症狀暨善終準備流程------------------------------------------------ 48
圖八 臨死覺知--------------------------------------------------------------------- 49
圖九 善終準備流程--------------------------------------------------------------- 50
圖十 安寧居家收案死亡結案病歷性別比------------------------------------ 53
圖十一 安寧居家病人死亡時狀況------------------------------------------------ 54
圖十二 喪親家屬哀傷系統--------------------------------------------------------- 55
圖十三 遺族關懷流程--------------------------------------------------------------- 56
圖十四 遺族關懷追蹤--------------------------------------------------------------- 57
圖十五 喪親家屬工作性質--------------------------------------------------------- 58
圖十六 哀傷的意義------------------------------------------------------------------ 59
圖十七 喪親家屬工作地點--------------------------------------------------------- 60
圖十八 工作時情緒------------------------------------------------------------------ 61
圖十九 與同事關係------------------------------------------------------------------ 62
圖二十 對工作的期待--------------------------------------------------------------- 63
圖二十一 其他有意義活動------------------------------------------------------------ 64
圖二十二 情緒--------------------------------------------------------------------------- 65

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