• 沒有找到結果。

第六章 結論與建議

6.2 後續研究建議

一、不同的安寧緩和醫師如何面對自己與親人的死亡

本研究此次並未探討安寧緩和醫師面對自己死亡的態度、準備與看法。另 外,醫師面對親人死亡時的經驗與想法如何,若能夠知道不同的安寧緩和醫師本 身面對死亡的態度、經驗與看法,將更有助於未來協助病人做死亡準備。

二、其他科醫師如何協助病人面對死亡

本研究為從安寧緩和醫師出發之死亡準備觀點,其他科醫師未必適用,若未 來有機會可以再進行相關研究。

三、死亡準備與靈性照顧之間的關係

本研究發現對於安寧緩和醫師而言,死亡準備過程可適用於與靈性照顧之天 人物我關係和諧模式,但是否適用於其他職類,或其他專科醫師、其他民眾等,

還續後續研究探討。

參考文獻

1. Steinhauser, K.E., et al., In search of a good death: observations of patients, families, and providers. Ann Intern Med, 2000. 132(10): p. 825-32.

2. Steinhauser, K.E., et al., Preparing for the end of life: preferences of patients, families, physicians, and other care providers. J Pain Symptom Manage, 2001.

22(3): p. 727-37.

3. Cassel, M.J.F.a.C.K., Approaching Death: Improving care at the end of life.

INSTITUTE OF MEDICINE, NATIONAL ACADEMY PRESS Washington, D.C., 1997. .

4. Emanuel, E.J. and L.L. Emanuel, The promise of a good death. The Lancet, 1998. 351: p. SII21-SII29.

8. Hebert, R.S., Q. Dang, and R. Schulz, Preparedness for the death of a loved one and mental health in bereaved caregivers of patients with dementia: findings from the REACH study. J Palliat Med, 2006. 9(3): p. 683-93.

9. McLeod-Sordjan, R., Death preparedness: a concept analysis. J Adv Nurs, 2014.

70(5): p. 1008-19.

10. Lunney, J.R., et al., Patterns of functional decline at the end of life. Jama, 2003.

289(18): p. 2387-92.

11. Schulz, R., et al., End-of-life care and the effects of bereavement on family caregivers of persons with dementia. N Engl J Med, 2003. 349(20): p. 1936-42.

12. Durepos, P., et al., What Does Death Preparedness Mean for Family Caregivers of Persons With Dementia? Am J Hosp Palliat Care, 2019. 36(5): p. 436-446.

13. Durepos, P., et al., Caregiver preparedness for death in dementia: an evaluation of existing tools. Aging Ment Health, 2019: p. 1-10.

14. Noonan, K., et al., Developing death literacy. Progress in Palliative Care, 2016.

24(1): p. 31-35.

15. Horsfall, D., et al., End of life at home: co-creating an ecology of care. 2015.

16. 鄭企峰, 林承霈, and 蕭勝煌, 提升死亡識能以提供高品質晚期癌症照護.

北市醫學雜誌, 2018. 15: p. 54-60.

17. 黃喬煜, et al., 提升「死亡識能」-推廣在宅善終的高價值照護. 北市醫學 雜誌, 2017. 14(3): p. 269-278.

18. 陳端容 and 吳丕玉, 從公衛觀點談病人自主權利法與「死亡識能」的增 能. 台灣公共衛生雜誌, 2019. 38(2): p. 111-114.

19. Bugen, L.A., Coping: Effects of death education. Omega (Westport), 1980-81.

11: p. 175-183. .

20. Robbins, Death competency: a study of hospice volunteers.. Death Studies, 1992. 16: p. 557-569.

24. Nedjat-Haiem, F.R., et al., Exploring Health Care Providers' Views About Initiating End-of-Life Care Communication. Am J Hosp Palliat Care, 2017.

34(4): p. 308-317.

25. Houttekier, D., et al., Is physician awareness of impending death in hospital related to better communication and medical care? J Palliat Med, 2014. 17(11):

p. 1238-43.

26. Bloomer, M.J., et al., The 'dis-ease' of dying: challenges in nursing care of the dying in the acute hospital setting. A qualitative observational study. Palliat Med, 2013. 27(8): p. 757-64.

27. Best, M., P. Butow, and I. Olver, The doctor's role in helping dying patients with cancer achieve peace: a qualitative study. Palliat Med, 2014. 28(9): p. 1139-45.

28. Glare, P., et al., A systematic review of physicians' survival predictions in terminally ill cancer patients. Bmj, 2003. 327(7408): p. 195-8.

29. Christakis, N.A. and E.B. Lamont, Extent and determinants of error in doctors' prognoses in terminally ill patients: prospective cohort study. Bmj, 2000.

320(7233): p. 469-72.

30. White, N., et al., A Systematic Review of Predictions of Survival in Palliative Care: How Accurate Are Clinicians and Who Are the Experts? PLoS One, 2016.

11(8): p. e0161407.

31. Geijteman, E.C.T., et al., Interventions in hospitalised patients with cancer: the importance of impending death awareness. BMJ Support Palliat Care, 2018.

8(3): p. 278-281.

32. Forbes, K., The diagnosis of dying. J R Coll Physicians Lond, 1999. 33(3): p.

287.

33. Kennedy, C., et al., Diagnosing dying: an integrative literature review. BMJ Support Palliat Care, 2014. 4(3): p. 263-70.

34. Bern-Klug, M., The ambiguous dying syndrome. Health Soc Work, 2004. 29(1):

p. 55-65.

35. Ellershaw, J. and C. Ward, Care of the dying patient: the last hours or days of life. Bmj, 2003. 326(7379): p. 30-4.

36. Toscani, F., et al., How people die in hospital general wards: a descriptive study.

J Pain Symptom Manage, 2005. 30(1): p. 33-40.

37. Scott, K., Incidence of sudden, unexpected death in a specialist palliative care inpatient setting. Palliat Med, 2010. 24(4): p. 449-50.

38. Wilcock, A. and V. Crosby, Hospices and CPR guidelines. Sudden and unexpected death in a palliative care unit. BMJ, 2009. 338: p. b2343.

39. Bruera, S., et al., Frequency and factors associated with unexpected death in an acute palliative care unit: expect the unexpected. J Pain Symptom Manage, 2015. 49(5): p. 822-7.

40. Burton, A.M., W.E. Haley, and B.J. Small, Bereavement after caregiving or unexpected death: effects on elderly spouses. Aging Ment Health, 2006. 10(3):

p. 319-26.

41. Keyes, K.M., et al., The burden of loss: unexpected death of a loved one and psychiatric disorders across the life course in a national study. Am J Psychiatry, 2014. 171(8): p. 864-71.

42. Barry, L.C., S.V. Kasl, and H.G. Prigerson, Psychiatric disorders among

bereaved persons: the role of perceived circumstances of death and preparedness for death. Am J Geriatr Psychiatry, 2002. 10(4): p. 447-57.

43. Ozanne, E.M., et al., Doctor-patient communication about advance directives in metastatic breast cancer. J Palliat Med, 2009. 12(6): p. 547-53.

44. Angelos, P. and M.R. Kapadia, Physicians and cancer patients: communication and advance directives. Cancer Treat Res, 2008. 140: p. 13-28.

45. Wentlandt, K., et al., Preparation for the end of life in patients with advanced cancer and association with communication with professional caregivers.

Psychooncology, 2012. 21(8): p. 868-76.

46. Sullivan, A.M., et al., Diagnosing and discussing imminent death in the hospital:

a secondary analysis of physician interviews. J Palliat Med, 2007. 10(4): p. 882-93.

47. Lamont, E.B. and N.A. Christakis, Prognostic disclosure to patients with cancer near the end of life. Ann Intern Med, 2001. 134(12): p. 1096-105.

48. Gordon, E.J. and C.K. Daugherty, 'Hitting you over the head': oncologists' disclosure of prognosis to advanced cancer patients. Bioethics, 2003. 17(2): p.

142-68.

49. Abarshi, E., et al., Discussing end-of-life issues in the last months of life: a nationwide study among general practitioners. J Palliat Med, 2011. 14(3): p.

323-30.

50. Glaser, B.G. and A.L. Strauss, Awareness of dying. Awareness of dying. 1965, New Brunswick, NJ, US: AldineTransaction. xi, 305-xi, 305.

51. Enzinger, A.C., et al., Outcomes of Prognostic Disclosure: Associations With Prognostic Understanding, Distress, and Relationship With Physician Among Patients With Advanced Cancer. J Clin Oncol, 2015. 33(32): p. 3809-16.

52. Lundquist, G., B.H. Rasmussen, and B. Axelsson, Information of imminent death or not: does it make a difference? J Clin Oncol, 2011. 29(29): p. 3927-31.

53. Belanger, E., et al., Initiating decision-making conversations in palliative care:

an ethnographic discourse analysis. BMC Palliat Care, 2014. 13: p. 63.

54. Daugherty, C.K. and F.J. Hlubocky, What are terminally ill cancer patients told about their expected deaths? A study of cancer physicians' self-reports of prognosis disclosure. J Clin Oncol, 2008. 26(36): p. 5988-93.

55. Wood, W.A., M.S. McCabe, and R.M. Goldberg, Commentary: Disclosure in oncology -- to whom does the truth belong? Oncologist, 2009. 14(1): p. 77-82.

56. Schmit, J.M., et al., Perspectives on death and dying: a study of resident comfort with End-of-life care. BMC Med Educ, 2016. 16(1): p. 297.

57. Meghani, S.H. and P.S. Hinds, Policy brief: The Institute of Medicine report Dying in America: Improving quality and honoring individual preferences near the end of life. Nursing outlook, 2015. 63(1): p. 51-59.

58. 林晏群, 安寧緩和醫療教育課程對醫學生知識與態度之影響: 從 2007 到 2011 年某醫學院之調查研究, in 醫學人文研究所. 2013, 臺北醫學大學. p.

1-110.

59. Cripe, L.D., et al., Medical Students' Professionalism Narratives Reveal That Experiences With Death, Dying, or Palliative Care Are More Positive Than Other Experiences During Their Internal Medicine Clerkship. Am J Hosp Palliat Care, 2017. 34(1): p. 79-84.

60. Arnold, B.L., L.S. Lloyd, and C.F. von Gunten, Physicians' Reflections on Death and Dying on Completion of a Palliative Medicine Fellowship. J Pain Symptom Manage, 2016. 51(3): p. 633-9.

61. Udo, C., et al., Palliative care physicians' experiences of end-of-life

communication: A focus group study. Eur J Cancer Care (Engl), 2018. 27(1).

62. Kehl, K.A., How hospice staff members prepare family caregivers for the patient's final days of life: an exploratory study. Palliat Med, 2015. 29(2): p.

128-37.

63. 楊惠玲, et al., 護理人員照顧末期病人的情緒困擾與死亡因應自我效能之關 聯-以北部某醫學中心為例. 安寧療護雜誌, 2016. 21(1): p. 16-29.

64. 釋宗惇, et al., 安寧緩和醫療之死亡準備. 安寧療護雜誌, 2006. 11(2): p. 117-136.

65. 釋普安, et al., 居家善終靈性照顧. 安寧療護雜誌, 2011. 16(1): p. 82-94.

66. Hebert, R.S., et al., Preparing caregivers for the death of a loved one: a

theoretical framework and suggestions for future research. J Palliat Med, 2006.

9(5): p. 1164-71.

67. Balducci, L., Death and dying: what the patient wants. Ann Oncol, 2012. 23 Suppl 3: p. 56-61.

68. C. Sherman, A., et al., Cancer patient perspectives regarding preparedness for end-of-life care: A qualitative study. Vol. 36. 2018. 1-16.

69. 萬文隆, 深度訪談在質性研究中的應用. 生活科技教育, 2004. 37(4): p. 17-23.

70. 潘淑滿, 質性研究:理論與應用. 臺北市:心理, 2006.

71. 鈕文英, 質性研究方法與論文寫作. 台北市,雙葉書廊, 2012.

72. Benjamin F. Crabtree , E.b.W.L.M., Doing Qualitative Research. 2002.

73. Meier, E.A., et al., Defining a Good Death (Successful Dying): Literature Review and a Call for Research and Public Dialogue. Am J Geriatr Psychiatry, 2016. 24(4): p. 261-71.

74. Hebert, R.S., et al., Preparing family caregivers for death and bereavement.

Insights from caregivers of terminally ill patients. J Pain Symptom Manage, 2009. 37(1): p. 3-12.

75. Hamano, J., et al., Trust in Physicians, Continuity and Coordination of Care, and Quality of Death in Patients with Advanced Cancer. J Palliat Med, 2017. 20(11):

p. 1252-1259.

76. Brennan, N., et al., Trust in the health-care provider-patient relationship: a systematic mapping review of the evidence base. Int J Qual Health Care, 2013.

25(6): p. 682-8.

77. Murray, B. and S. McCrone, An integrative review of promoting trust in the patient-primary care provider relationship. J Adv Nurs, 2015. 71(1): p. 3-23.

78. Yedidia, M.J., Transforming doctor-patient relationships to promote patient-centered care: lessons from palliative care. J Pain Symptom Manage, 2007.

33(1): p. 40-57.

79. Chao, C.S., C.H. Chen, and M. Yen, The essence of spirituality of terminally ill patients. J Nurs Res, 2002. 10(4): p. 237-45.

80. 趙可式, 安寧緩和療護的靈性關懷與天主教信仰. 醫病平台 聯合報元氣網, 2019.

81. 張利中, 王萱萁, and 陳郁分, 安寧護理人員的靈性照顧認知-以中部某醫 學中心安寧病房為例之研究. 醫學教育, 2006. 10(1): p. 62-69.

82. 林沄萱, 劉淑惠, and 陳清惠, 靈性護理之臨床應用. 護理雜誌, 2008. 55(3):

p. 69-74.

83. Kehl, K.A., Moving toward peace: an analysis of the concept of a good death.

Am J Hosp Palliat Care, 2006. 23(4): p. 277-86.

84. Ho, A.H., et al., Dignity amidst liminality: healing within suffering among Chinese terminal cancer patients. Death Stud, 2013. 37(10): p. 953-70.

85. Githaiga, J.N. and L. Swartz, Socio-cultural contexts of end- of- life

conversations and decisions: bereaved family cancer caregivers' retrospective co-constructions. BMC Palliat Care, 2017. 16(1): p. 40.

86. Mui Hing June Mak, A review of Promoting a Good Death for Cancer Patients of Asian Culture: An Evidenced-Based Approach by. London, UK: Whiting &

Birch Ltd., 2007: p. 328 pp. .

87. Schwartz, P.Y., Good Death in the Chinese Culture: A Relational Perspective.

Death Studies, 2010. 34(3): p. 278-284.

88. Moon, P.J., Death-talks: transformative learning for physicians. Am J Hosp Palliat Care, 2008. 25(4): p. 271-7.

89. Park, C., et al., A Multicenter Study Investigating Empathy and Burnout Characteristics in Medical Residents with Various Specialties. J Korean Med Sci, 2016. 31(4): p. 590-7.

附 錄 附錄一 訪談指引(interview guide)

訪談前

□ 根據取樣之對象寄送邀請函並私下詢問意願

□ 與受訪者確認受訪時間與地點,並將受訪同意書與訪談大綱先寄送至受訪者 電子信箱

□ 準備相關文件(受訪同意書、訪談大綱)、準備器材(錄音筆、手機、隨身筆 記、筆)

□ 準備受訪者之訪談費用 1000 元與領據 訪談當日

□ 填寫受訪同意書與受訪者基本資料

□ 填寫計畫核銷領據、給予受訪者訪談費用

□ 進行訪談 (30 分-60 分)

□ 先進行暖場式問題(從事安寧的初衷、現在工作的類型..)

□ 再詢問訪談大綱主要問題內容

□ 結束訪談

□ 確認資料蒐集完畢

□ 感謝受訪者 訪談後

□ 請研究助理謄寫逐字稿

□ 逐字稿校對(研究者)與初步分析

□ 寄送逐字稿給受訪者檢核校對

□ 請受訪者填寫基本資料表與逐字稿校對回傳

□ 逐字稿編碼及去辨識化

□ 確認最後訪談逐字稿文本

附錄二 訪談大綱

1. 您投入安寧的契機與緣由?

2. 對您而言,甚麼是死亡準備?

3. 您如何對病人或家屬做死亡準備?在您照顧末期病人的經驗中,

有讓您印象深刻的死亡準備過程嗎?

4. 您認為何時開始做死亡準備是適當的?

5. 您覺得在死亡準備的過程中有哪些關鍵因素? 哪些是阻礙? 哪 些是助力?

6. 您覺得甚麼樣的死亡準備對您而言是完備的,您都如何確認病 人或家屬是否準備好了?

7. 面對想法不同的家屬,您如何做溝通協調,使不同成員的意見 能趨於一致,共同進入死亡準備的過程?

8. 您覺得醫師在死亡準備過程中所扮演的角色為何? 跟其他團隊

成員有何不同?

附錄三 受訪者基本資料表 1. 年齡:_____歲

2. 性別:□男 □女

3. 婚姻:□未婚 □已婚 □離婚 □分居 □鰥寡 4. 專科:□家庭醫學科 □放射腫瘤科 □血液腫瘤科

□其他 __________

5. 宗教信仰:□無 □佛教 □道教 □基督教 □天主教 □其他 _________

6. 工作年資:______年,臨床參與安寧緩和醫療工作時間 ____ 年

7. 工作醫院型態:□醫學中心 □區域醫院 □地區醫院 □診所

□其他_____

附錄四 受訪同意書

附錄五 研究倫理審查通過證明

全文完