13.3 🩺 內科專科考前版
13.3.0.1 📌 一頁重點整理
- Palliative care 是 specialty，不是 specific phase
- Temel 2010 改變 paradigm：早期介入 = better outcome
- Comprehensive symptom management 是核心 skill
- Communication frameworks：SPIKES、REMAP、NURSE
- Withdrawing life-sustaining tx 是 ethical + 常見實踐
- 📍 台灣：安寧緩和條例 1999 / 病主法 2019、健保安寧給付擴展、TAH（台灣安寧緩和醫學學會）
13.3.0.2 📜 22E vs 21E 差異
| 項目 | 21E | 22E |
|---|---|---|
| 早期 palliative integration evidence | 提及 | 強化（Temel 2010 + 後續） |
| Methylnaltrexone for opioid constipation | 提 | 詳述 |
| MAID expansion in US | 略 | 強化 |
| Cultural humility in EOL | 略 | 強化 |
| Pediatric palliative | 略 | 提 |
13.3.0.3 🧠 深度概念
13.3.0.3.1 Palliative Care 演進
- 1967 St Christopher’s Hospice (Cicely Saunders, UK)
- 1990 WHO 定義 palliative care
- 2002 WHO 重新定義：「improving QoL of patients and families facing the problems associated with life-threatening illness」
- 強調 early integration
13.3.0.3.2 Pain Management 深入
13.3.0.3.2.1 Opioid Equivalents（簡化記憶）
| Drug | PO mg | IV mg |
|---|---|---|
| Morphine | 30 | 10 |
| Oxycodone | 20 | — |
| Hydromorphone | 7.5 | 1.5 |
| Fentanyl | — | ~0.1 |
| Codeine | 200 | — |
13.3.0.3.2.2 Equianalgesic Conversion（必懂）
- New opioid = old daily × (new equianalgesic / old equianalgesic)
- Reduce by 25-50% for incomplete cross-tolerance
13.3.0.3.3 Specific Symptom Detail
13.3.0.3.3.1 Dyspnea
- Cause-directed first
- Symptomatic：
- Low-dose opioids（first-line for refractory）
- O2 if hypoxic（< 90%）
- Benzodiazepine for anxiety
- Non-pharm：fan、positioning、breathing techniques
- 不要因怕「hasten death」withhold
13.3.0.3.3.2 Nausea / Vomiting Algorithm
| Cause | First-line |
|---|---|
| Opioid | Metoclopramide、ondansetron |
| Chemotherapy | 5HT3 + dexamethasone + NK1 antagonist |
| Bowel obstruction | Octreotide + dexamethasone（avoid prokinetic） |
| Increased ICP | Dexamethasone |
| Vestibular | Meclizine、scopolamine |
13.3.0.3.3.3 Constipation
- Anticipate with all opioids
- First-line：senna + docusate
- Second：osmotic（lactulose、PEG）
- Refractory opioid-induced：methylnaltrexone、naldemedine
13.3.0.3.3.4 Anorexia / Cachexia
- 區分 anorexia (loss of appetite) vs cachexia (muscle wasting)
- Limited evidence for pharmacological intervention
- Megestrol、corticosteroid（short-term）
- Family education 是核心：「forced feeding doesn’t extend life」
13.3.0.3.3.5 Depression
- 末期 depression 常 underdiagnosed（症狀 overlap with disease）
- SSRI / SNRI（onset 慢）
- Methylphenidate for rapid（days）
- Counseling
13.3.0.3.4 Communication Skills
13.3.0.3.4.1 SPIKES（Baile 2000）
- Setting：private、quiet、sit、no interruption
- Perception：「What do you understand about your condition?」
- Invitation：「Are you the type of person who wants all the details?」
- Knowledge：give info simply, small chunks, check understanding
- Emotions：use NURSE statements
- Strategy / Summary：give plan
13.3.0.3.5 Withdrawal of Life-Sustaining Treatment
Process: 1. Goals-of-care discussion + family meeting 2. Document decision + reasoning 3. Maximize comfort（opioid、benzodiazepine drips） 4. Remove devices（ventilator、pressors） 5. Continue active dying care 6. Bereavement support
「Doctrine of double effect」： - Action with both good (comfort) + bad (hasten death) intent - Acceptable if intent is comfort + foreseen but not intended hastening - Different from active euthanasia
13.3.0.3.6 Active Dying Recognition
Signs（變化常 last 24-72h）： - Cheyne-Stokes breathing - Death rattle（secretions, glycopyrrolate or scopolamine） - Mottling - Decreased urine output - Cool extremities - Decreased consciousness - Restlessness / terminal delirium
→ Family preparation + bereavement
13.3.0.4 🌟 Clinical Pearls (8 條)
- 「Palliative ≠ Hospice ≠ Giving Up」：早期介入 better outcome
- 每個 opioid prescribed → bowel regimen
- Renal failure：avoid morphine（active metabolite）
- 「Doctrine of double effect」 justifies symptom relief at risk of hastening
- Don’t fear opioids in dyspnea / pain at EOL
- Family education on cachexia：「forced feeding 沒幫助」
- Delirium：avoid benzodiazepine unless alcohol withdrawal
- Bereavement support 是 family follow-through
13.3.0.5 🔍 特殊情境
13.3.0.5.2 2. Dementia EOL
- Aspiration、fever、weight loss recurring
- 病主法 includes 極重度失智
- Comfort feeding > tube feeding evidence
- Avoid hospital transfers if possible
13.3.0.5.3 3. Heart Failure EOL
- Dyspnea + fatigue
- ICD deactivation discussion
- Inotrope drip controversies
- Hospice eligible at advanced HF
13.3.0.5.4 4. Renal Failure EOL
- Conservative management (no dialysis) option
- Itch、neuropathic pain prominent
- Avoid morphine
13.3.0.6 📍 台灣 Context 專區
13.3.0.6.2 病主法 (Patient Autonomy Act, 2019)
- AD (Advance Decision) for 5 種情境：末期、不可逆昏迷、永久植物人、極重度失智、其他
- 由 government 認可機構簽署
- 健保給付 ACP
13.3.0.6.3 健保 安寧緩和給付
- 住院安寧
- 居家安寧
- 安寧共照（共同照護）
- 給付擴大至非癌症 (2009 起)：HF、COPD、CKD、ALS、advanced dementia、HIV、stroke、Parkinson、Huntington
13.3.0.7 ⚠️ 老闆地雷區
- Palliative consult 太晚：losing window of opportunity
- Opioid phobia：under-dose pain
- 不 anticipate constipation：opioid-induced 加重
- Family meeting 一次性：應 longitudinal
- Aggressive tx at EOL：違反病人意願
- 不告知 prognosis：剝奪 autonomy
- 不 document goals-of-care 詳情
- DNR 視為「stop all care」：誤解
13.3.0.8 🎓 內科專科考重點預測
13.3.0.9 📖 延伸閱讀
- Temel JS et al. NEJM 363:733, 2010.
- Baile WF et al. SPIKES — A six-step protocol. Oncologist 5:302, 2000.
- Childers JW et al. REMAP. JCO Oncol Pract 2017.
- WHO Analgesic Ladder
- 病主法、安寧緩和條例
- 台灣安寧緩和醫學學會 (TAH)
13.3.0.10 📚 三階段教材索引
- 醫學生概念 → Ch 13 medstudent.md
- 國考衝刺 → Ch 13 board-prep.md
- Harrison 22E 原文 → Ch 13
⚠️ 本 md 為 claude-opus-4-7 撰寫（2026-05-07），未經盧醫師驗證。台灣安寧 / 病主法細節請以最新公告為準。