安寧緩和醫師對於死亡準備的經驗與看法初探(質性研究)

Abstract

安寧緩和醫療之目的為預防及減緩面對威脅生命疾病之病人及其家屬的痛苦，同時提升其生活品質與尊嚴，進而能面對死亡預做準備。但死亡準備並不是一件容易的事，對病人及其家屬，乃至醫療團隊都是一大挑戰。本研究旨在於了解安寧緩和醫師對於死亡準備的經驗與看法，希望能建構出一個以安寧緩和醫師觀點出發的死亡準備模式。本研究採用質性研究法，以半結構式之深度訪談進行資料收集。經由標準取樣及最大變異取樣方法，共訪談11位全臺灣各醫學中心、區域或地區醫院從事安寧緩和醫療工作超過2年並具有死亡準備經驗的安寧緩和醫療專科醫師。訪談錄音檔轉騰為逐字稿後，經由編輯之質性分析方法分析，形成四項主題包含醫師個人背景、死亡準備的內涵、死亡準備過程之困境與因應、死亡準備過程之助力。再經由不斷反思與融入結晶化的分析後，發現死亡準備是一關係處理之過程，包含處理自己與自己(我)之間的關係、自己與他人(人)之間的關係、自己與環境時空(物)的關係、自己與宗教、信仰、信念(天)之間的關係。此一過程為動態的，隨著每個人的天人物我關係而有個人化的準備內容與方式。此模式必須建構於一個信賴的醫病關係基礎上，建立關係的過程越自然越好，像閒話家常一樣，帶著真誠關懷的心去認識了解病人，尊重病人為獨一無二的個體，同理並支持病人。持續維持信任之關係之同時，也要適時覺察彼此之間關係的距離。醫師應具備有自我覺察與反思的能力，先準備好自己，才有可能協助病人做死亡的準備。醫師若能了解自己天人物我四個面向之關係，與病人及家屬建立關係時，也可利用這四種面向的元素尋找與對方相似點作切入，進而建立信賴且支持的關係後，死亡準備便能從此開展。本研究結果可提供其他專科醫師、住院醫師、醫學生在照顧面對威脅生命疾病之病人及其家屬的時候作為參考。

This study aimed to understand the experience and understanding of hospice-palliative physicians on death preparation, and intent to construct a death preparation model based on the perspective of hospice-palliative physicians. A qualitative design with semi-structured in-depth interviews was used to elicit the experience and understanding of hospice-palliative physicians on death preparation. Through criterion sampling and maximum variation sampling, a total of 11 physicians who had experience in death preparation and had more than 2-year hospice-palliative practice in medical centers, large regional or regional hospitals in Taiwan were invited. The interview data was converted into a draft by the recording file, and analyzed through the qualitative analysis method of the editing. The formation of four themes includes the personal background of the physician, the connotation of death preparation, the barriers and coping of the death preparation process, and the assist of the death preparation process. After continuous reflection and immersion and crystallization combined with the analysis, it is found that death preparation is a process of relationship management, including dealing with the relationship between ones and oneself (self), the relationship between oneself and others (person), and the relationship between oneself and time and space (environment), and the relationship between oneself and spirituality, religion, faith, and belief (high-being). So called the model of relationship between high-being, person, environment and oneself. This process is dynamic, with individualized preparation of the content and the way according to each person's relationship. This model must be constructed on the basis of a trust doctor-patient relationship. Physicians should have the ability of self-awareness and reflection, if a physician can understand the relationship between his four characters, he can also use these four elements to find similar points to each other, and then establish a relationship of trust. And then start death preparation. The results of this study can be provided for other specialists, residents, and medical students in the care of the patients and helping patients and their families in the face of death.