在生死与道德伦理间......

走进白衣天使的世界

版主: 安樂yuyawei

安樂
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大家是否知道, 什么是ethical dilemma? 其实它就代表了一个徘徊在道德伦理间,让人左右为难的状况. 例如在医学界, 当一名病人病入膏盲,无法医治,神智却还清醒; 在他要求安乐死的时候, 医护人员就陷入了ethical dilemma的困境. 这个状况, 在医学界是常见的. 相信许多护士都曾亲身体会过. 我在七月开始了护士学士课程 (degree in nursing), 这个课题希望能和大家分享.

先讲述一个个案, 希望大家能了解ethical dilemma的状况:

曾经, 在我工作的病房, 有一位末期肺癌的病人. 他是一名教师. 从他进院开始, 他对我们这些护士就特别尊敬. 每次从他房间出来, 不论我们做得好或不好, 他都会很诚恳的对我们说谢谢. 但是, 他的癌细胞, 已扩散到骨髓里. 那种痛入骨头里的感受, 他总是强忍着. 麻啡 (morphine—止痛药) 的剂量, 越打越高, 最后只能持续注入 (infusion). 而这位病人, 也因为这种药物, 陷入了昏睡状态.

病人就这样昏睡了几个星期, 他的太太在之前常要求我们替病人抽痰. 后来发现每次抽痰后病人都泪流满脸, 于是就要求我们尽量不要抽痰了. 但是, 由于病人长期昏睡, 肺活量不多, 导致肺发炎. 在呼吸间就能听到痰的声音. 不知道的人, 还以为护士都没做好工作, 不替病人抽痰.

这位病人求生的意志比普通人强, 所以病情拖了很久他也没有断气. 他的太太要求医生让病人早日离去, 这是因为他不想再看到病人痛苦下去.

这时候, 我们所有的医护人员就陷入了ethical dilemma的困境.

经过他的太太与医生讨论后, 医生吩咐我们在病人咳得很严重, 痰很多时, 替他打一针高剂量的麻啡, 来帮助病人死去. 医生把药名写在药单后就离去了. 一直在身旁照顾的我们, 谁也狠不下心来打这支药针. 毕竟, 护士学打针给药是要治疗病人, 让他们得以康复. 没有人想要背上杀手的罪过. 后来, 他的病情拖延了大约一个星期, 他还是自己断气了.

这时另一个我从文章 (journal) 里看到的个案:

一名博士得了一种自律神经中枢的病症, Shy Drager Syndrome. 这时种残忍的病症. 病人的头脑清醒, 和正常人一样. 但是, 他却使人慢慢地失去控制手脚的能力, 不能吞食, 甚至无法说话. 倘若是你, 得了这种病症, 你想说不能说, 想动不能动, 只能躺在病床上, 任人摆布. 那是多么的悲惨啊!

这名博士已完全了解自己的病症, 他已无法动弹, 只能勉强说几句话. 他对医生说自己已无法得救, 他明白若持续吃东西, 他可能会被啃死. 但是, 他希望能吃食物, 直到自己死去为止. 这个请求, 也让医护人员陷入了ethical dilemma的困境.

这是病人的意愿, 但是, 你们是否能了解我们护士在喂这名病人吃东西的心情? 若你是一名护士, 你该怎么做?

我的讲师告诉我们三样最重要的事项:
1. Autonomy -尊重病人的意愿
2. Beneficence -选择对病人有利益的决定
3. Nonmaleficence -选择不伤害病人的决定
考虑了这三样事项后, 再想想以下四个道理 (principle) , 才决定:
1. Veracity -给予诚实, 准确的解释
2. Justice -公平合理
3. Confidentiality -尊重病人的私隐权
4. Role fidelity -保持护士该有的角色
(若翻译不准确, 别见怪)

在ethical dilemma的困境里, 护士是病人与家属的顾问. 他们的决定, 往往取决于护士和医生的解释.
愿以这七个道理 (principle), 与护士们共勉之.
不求福寿安康, 但求智慧明睿; 不求事事如意, 但求毅力勇气; 不求减轻负担, 但求增加力量.
博文
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我能感受到,如果我是病人

我需要家人为我诵经、祈祷、祝福。
我需要有理性有方向的然后不再留恋尘世
我虽然不能形容痛苦,但若能减轻精神上的痛苦,唯有精神克服神经。

——建议的方法,是通过助念。
我重重地离去,带走一切云彩——李敖
yuyawei
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安樂 写道:
经过他的太太与医生讨论后, 医生吩咐我们在病人咳得很严重, 痰很多时, 替他打一针高剂量的麻啡, 来帮助病人死去. 医生把药名写在药单后就离去了. 一直在身旁照顾的我们, 谁也狠不下心来打这支药针. 毕竟, 护士学打针给药是要治疗病人, 让他们得以康复. 没有人想要背上杀手的罪过. 后来, 他的病情拖延了大约一个星期, 他还是自己断气了.
Just out of my curiosity,

1. Do you consider this as active euthanasia when you carried out the doctor's order?

2. Did the doctor verbalised/ explained that his action is to help patient to die fast?

3. From question no. 2, if yes, did the doctor obtained written consent from the family?

4. From question No. 2 and No. 3, is Euthanasia legal in our country? ( This is a big puzzle when I read this statement '替他打一针高剂量的麻啡, 来帮助病人死去'.)

5. and last question, did the doctor disscussed the issue with nurses when he encounter this dillemma? I found most of the doctor do not touch this topic with nurses, do you agree with me?
Sow a thought, reap an action;Sow an action, reap a habit;Sow a habit, reap a character;Sow a character, reap a destiny.
yuyawei
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I did a bit of net surfing today to find out more about Euthanasia.

Active euthanasia or euthanasia by action happend when the physician is giving lethal injection to the patient to cause death.

If the physician prescribed high-doses of analgesia to a chronic pain patient that may endangered life, when they have been shown necessary is NOT euthanasia. Thus, nursing profession should not be afraid to give high-dose of morphine when it is deemed necessary unless death is intended.
Sow a thought, reap an action;Sow an action, reap a habit;Sow a habit, reap a character;Sow a character, reap a destiny.
豪坤
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人工流产 (abactio),同样也会处于 ethical dilemma 。

安乐死在马来西亚无法实行,会被归类为谋杀案处理。
安樂
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yuyawei 写道:
安樂 写道:
经过他的太太与医生讨论后, 医生吩咐我们在病人咳得很严重, 痰很多时, 替他打一针高剂量的麻啡, 来帮助病人死去. 医生把药名写在药单后就离去了. 一直在身旁照顾的我们, 谁也狠不下心来打这支药针. 毕竟, 护士学打针给药是要治疗病人, 让他们得以康复. 没有人想要背上杀手的罪过. 后来, 他的病情拖延了大约一个星期, 他还是自己断气了.
Just out of my curiosity,

1. Do you consider this as active euthanasia when you carried out the doctor's order?

2. Did the doctor verbalised/ explained that his action is to help patient to die fast?

3. From question no. 2, if yes, did the doctor obtained written consent from the family?

4. From question No. 2 and No. 3, is Euthanasia legal in our country? ( This is a big puzzle when I read this statement '替他打一针高剂量的麻啡, 来帮助病人死去'.)

5. and last question, did the doctor disscussed the issue with nurses when he encounter this dillemma? I found most of the doctor do not touch this topic with nurses, do you agree with me?
Yes, ya wei, i do agree this action is euthanasia. Its not legal in Malaysia. This decision came out after doctor discuss with patient's wife. He meant to relax the muscle in the airway when patient have alot of secretion. So that, patient's airway will be blocked by the secretion and died. Patient's wife also agreed, but he didn't obtain any written consent.

This doctor do explain to the nurses on duty that day about patient's wife request and the purpose of giving the morphine. The nurses on duty have actually told him to give the injection himself. But he refused, because this patient is actually his relatives.

I do agree that doctor won't discuss all this issue with nurses. They usually spend alot of time to discuss with family. After that they will just write it down and leave. In another hand, i think nurses also should voice out if we found the decision is not right. But this is also depends on the nurses enthusiasm and experience.
不求福寿安康, 但求智慧明睿; 不求事事如意, 但求毅力勇气; 不求减轻负担, 但求增加力量.
安樂
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博文 写道:我能感受到,如果我是病人

我需要家人为我诵经、祈祷、祝福。
我需要有理性有方向的然后不再留恋尘世
我虽然不能形容痛苦,但若能减轻精神上的痛苦,唯有精神克服神经。

——建议的方法,是通过助念。
很可惜这个社会有太多人没有宗教信仰, 再不然就是不虔诚.

在我遇见的垂死病人里, 可能一千个里只有一个是有家人时时在身旁助念的.

有时候乘有空, 又没人的时候, 我会替病人念一遍心经.

我也有个梦想, 希望能开办一间佛教的临终关怀医院. 那么, 大家就能为许多人一起助念了.
不求福寿安康, 但求智慧明睿; 不求事事如意, 但求毅力勇气; 不求减轻负担, 但求增加力量.
豪坤
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安樂 写道:我也有个梦想, 希望能开办一间佛教的临终关怀医院. 那么, 大家就能为许多人一起助念了.
外国好像有临终关怀护士的 :oops:
潘强华
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豪坤 写道:人工流产 (abactio),。

abortion 是流产,不是人工流产.


abortion 有几种:

1.threathened abortion 是指胎儿受到威胁,不过还没有流产.

2.missed abortion 是指胎儿已经死在子宫内.

3.inevitable abortion 是指胎儿将不保,随时都会死.

4.habitual abortion 是指流产多次了.
yuyawei
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:shock: What a shock to me!! It's not mercy at all, it sounds like murder rather than euthanasia!! Choke to death by own phlegm is what kind of experience, can't imagine of it!!

We keep the doctor aside, let's talk about our part. As you said, nursing staff shouldn't be quiet when doubt what is morally right, this is really a strong point of view. If we do not advocate for the vulnerable patient, who else?

Nursing is always a team, for such issue, attention to nursing administrator should be emphasized.

Basic nursing care for a dying / terminally ill patient shouldn't be withdrawn even no code status is being decided. For instance, suctioning of secertion from the airway is deemed very very basic, and even the patient's loved one requested not to do so, we should convince them that the suctioning is beneficial to patient by providing relevant and accurate information, and I believe it will change their mind.

** This is an interesting topic, I enjoy such constructive discussion. Hope that TSL and 精 will also join in!
Sow a thought, reap an action;Sow an action, reap a habit;Sow a habit, reap a character;Sow a character, reap a destiny.
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