| 摘要: | 呼吸困難是癌末病人極困擾之症狀，發生率高達50-70%，許多病人描述呼吸困難比疼痛更令人憂慮不安，不但讓照顧者不知所措，更嚴重影響末期生活品質。為了有效提升癌末呼吸困難照顧品質，本研究比較胸腔專科病房與安寧病房呼吸困難照護之效益，分析並整合所長，期望癌末病人能獲得更適切的處置及良好的照護。以觀察、訪談收集中部某醫學中心兩病房呼吸困難病人質、量性資料。共收得胸腔專科病房34人與安寧病房12人，各進行7天的觀察。
研究結果發現，兩病房病人經處置照護後呼吸困難症狀與日常生活皆有明顯改善，然而焦慮及憂鬱的改善卻無顯著差異。隨著病情變化，病人對照護的整體滿意度及舒適度卻有下降，且胸專病房呈現顯著差異。在訪談資料中，病人對呼吸困難主觀之經驗包括吸不到空氣、痛苦難耐、像似窒息及溺水的感覺、隨時擔心害怕再次喘起來的霎那，甚至因此擔憂死亡的來臨。胸專病房對呼吸困難的感受更為強烈，半數以上表示其對情緒影響甚巨。多數病人認為氧氣治療與嗎啡一般能有效改善喘，且大多數病人有其自我調適的因應方法，如以保持冷靜、調整活動量、減緩動作、尋找涼爽及通風環境、扇子搧風、電風扇吹臉等來改善其喘。進一步分析醫療照護，安寧病房嗎啡、緩和鎮靜劑的使用高於胸專病房，且著重心理諮商會談、靈性照護及跨專科團隊照護；而胸專病房在抗生素、肋膜放液、輸血等醫療處置及呼吸訓練及胸腔物理治療等照護高於安寧病房。
來自於照顧理念的不同、治療及照護目標的差異，胸專及安寧病房對癌末呼吸困難症狀的思考決策也有所差別。本研究結果建議，將兩病房之優點整合，胸專病房可學習安寧病房藉由醫病溝通、調整醫療目標並達成共識，同時加強嗎啡及緩和鎮靜劑之使用以有效緩解喘與不適之症狀；而安寧病房亦可考慮胸專病房做法，針對喘之可逆原因，提供積極的處置，適時地評估以矯正呼吸困難之導因。
Dyspnea is a common and distressing symptom in patients with advanced cancer. The prevalence of dyspnea ranges from 50-70%. Many patients considered it more distressing than pain, which made families and caregivers frustrated and seriously impair the patient’s end of life quality. This study had analyzed both qualitative and quantitative data collected from a chest ward and a hospice ward of a medical center situated in the middle of Taiwan, through observations and interviews. The participants include 46 patients, 34 of which were from the chest ward and 12 the other. The observation period lasted seven days. The goal was to compare the management of dyspnea in both wards in the hope of finding more effective interventions and cares that could benefit advanced patients.
The analysis showed that after the management of dyspnea, the symptom and QOL of the patients from both wards were improved, but the anxiety and depression levels were not. As the sickness evolved, the general satisfaction and comfort level with the care declined, and this was more significant in the chest ward than in the hospice ward. In the interviews, the patients described their dyspnea as inability to get enough air, suffocation, and expressed great anxiety and even fear of death. The patients in the chest ward felt stronger for dyspnea, half of which thought it seriously affected their emotions. Most of the patients considered oxygen therapy as good as morphine for relieving dyspnea. Besides, the patients had their own ways of coping it, such as staying calm, slowing down, finding a well-ventilated place, fanning, turning on the fan toward the face, etc. On the part of the clinical management, the usage of morphine and palliative sedation therapy is more frequent in the hospice ward than in the other; whereas the chest ward put more emphasis on antibiotics, pleural effusion drainage, blood transfusion, breathing exercises, and the chest physiotherapy. Furthermore, the hospice ward also offered psychological counseling, spiritual care services and inter-professional patient care.
As the goal of treatment of the two wards differs, so do the strategies for treating dyspnea. The result of this study suggested it best to combine the advantages of the two wards. That is, the chest ward could focus more on physician-patient communications to adjust its clinical goals with the assent of the patient. Besides, morphine and palliative sedative therapy could be used more often for dyspnea alleviation. While the hospice ward could learn from the chest ward by focusing on the reversible causes of the dyspnea and giving active treatments. |
