13.1 🎓 醫學生版
給醫學系 M3-M6：每個內科醫師都會遇到末期病人。配 Harrison 22E Ch 13 原文 對照閱讀。
13.1.0.1 📌 一頁重點整理 (TL;DR)
- Palliative care ≠ Hospice：
- Palliative care 任何 stage（serious illness）都可介入
- Hospice 預期 < 6 個月生命
- Palliative care 4 個 domains：physical、psychological、social、spiritual
- 早期 palliative care 改善 QoL + 甚至 survival（Temel et al. 2010 lung CA）
- Symptom management 8 大重點：pain、dyspnea、nausea、fatigue、depression、anxiety、constipation、anorexia
- Pain ladder (WHO)：non-opioid → weak opioid → strong opioid
- Bad news 告知 SPIKES：Setting、Perception、Invitation、Knowledge、Emotions、Strategy
- Goals-of-care 對話 是 longitudinal
- Withdrawing life-sustaining treatment 是 ethical + 常見實踐
🎯 三件事必須記住 1. Palliative ≠ Hospice 2. 早期介入更好 3. Bad news 用 SPIKES
13.1.0.2 🧠 核心概念
13.1.0.2.1 Palliative Care vs Hospice
| 面向 | Palliative Care | Hospice |
|---|---|---|
| 適應症 | 任何 serious illness | 預期 < 6 mo |
| Curative tx | 可同時 | 通常停止 |
| 提供者 | Hospital、clinic、home | Home、hospice facility |
| 給付 | 健保給付 | Medicare hospice benefit (US) |
| 焦點 | QoL + symptom + family | 同 + dying process |
13.1.0.2.2 Palliative Care 4 Domains
- Physical：pain、symptom
- Psychological：depression、anxiety、fear
- Social：family、financial、caregiving
- Spiritual：meaning、religion、forgiveness
→ Multidisciplinary team approach
13.1.0.2.3 早期 Palliative Care Evidence
Temel et al. 2010 NEJM：metastatic NSCLC 隨機分組 - Standard care vs early palliative care + standard - Early palliative：QoL 更好、depression 少、survival 更長（11.6 vs 8.9 月） - → 翻轉「palliative = giving up」誤解
13.1.0.2.4 主要 Symptom Management
13.1.0.2.4.1 Pain
WHO Analgesic Ladder: 1. Step 1: Non-opioid（acetaminophen、NSAID）± adjuvant 2. Step 2: Weak opioid（codeine、tramadol）± non-opioid ± adjuvant 3. Step 3: Strong opioid（morphine、oxycodone、fentanyl）± non-opioid ± adjuvant
Adjuvants: - Neuropathic：gabapentin、pregabalin、TCA、SNRI - Bone pain：bisphosphonate、radiation - Visceral pain：anti-spasmodics
Opioid 原則: - Around-the-clock dosing for chronic pain - Breakthrough：immediate-release 10-15% daily total - Anticipate + prevent constipation（all opioids） - Anticipate nausea (first 1 wk often) - Rotate opioids if tolerance / side effect
13.1.0.2.4.2 Dyspnea
- Treat underlying cause
- Symptomatic：opioids（low-dose）、O2 if hypoxic、benzodiazepines for anxiety
- Non-pharm：fan、positioning
13.1.0.2.4.3 Nausea/Vomiting
- Specific cause-directed
- Antiemetics：5HT3 antagonist、metoclopramide、haloperidol、olanzapine、dexamethasone
13.1.0.2.4.4 Fatigue
- Underlying：anemia、depression、sleep
- Energy conservation
- Methylphenidate (selected)
13.1.0.2.4.5 Depression / Anxiety
- SSRI / SNRI（注意 onset 慢）
- Methylphenidate for rapid-onset
- Benzodiazepine（careful）
- Counseling、CBT
13.1.0.2.5 Communication Skills
13.1.0.2.5.1 SPIKES Protocol（Bad News）
- Setting：private、quiet、sit、eye contact
- Perception：先了解病人 know what
- Invitation：問病人想知道多少
- Knowledge：給訊息（簡單語言、small chunks）
- Emotions：empathic response
- Strategy / Summary：給 next-step plan
13.1.0.2.6 Advance Care Planning
- Living will / advance directive
- POLST / MOLST
- Healthcare proxy / MPOA
- DNR / DNI / AND
- 病主法（台灣）
13.1.0.4 💡 Case 討論
62 歲男性 metastatic pancreatic CA，目前 chemo refractory。家屬問你：「還能做什麼？」
Approach: 1. Goals-of-care（REMAP） - Reframe：「治癒不可能但 comfort + meaningful time」 - Map：病人想做什麼？wedding 想參加？ 2. Symptom management - Pain：opioid + adjuvant（neuropathic from tumor） - Anorexia / cachexia：family education - Anxiety / depression：SSRI、counseling 3. Palliative care consult 4. Hospice referral if < 6 mo expectancy 5. Family support：caregiving education、bereavement 6. Spiritual care：if patient interested 7. Continue evaluating disease + symptom
13.1.0.5 📚 想深入請看
- 國考重點 → Ch 13 board-prep.md
- 內專考前版 → Ch 13 specialist.md
- Ethics → Ch 12
- Practice of Medicine → Ch 1
- Harrison 22E 原文 → Ch 13
⚠️ AI 草稿，未經盧醫師驗證。