급성기 중증 뇌졸중 환자의 치료 의사결정
Ethical Analysis of the Decision-making Process for Patients with Acute Severe Stroke
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초록
고령의 중증 뇌졸중 환자에서 뇌압을 낮추기 위해 반두개졀개술이 제안된 환자의 사례를 의학적 적 응증, 환자의 선호, 삶의 질, 맥락적 특성으로 구성된 4분면 접근법(the four topics chart)를 활용하여 분석하였다. 환자는 급성의 위중한 상황으로 반두개절제술로 생존 가능성을 높일 수는 있으나 위급한 상황을 넘겨 안정적이 되었을 때 일상생활의 전부, 혹은 상당 부분을 타인에게 의존해야 하며, 인지저 하가 예상된다. 환자의 삶의 질이 매우 낮을 것으로 예상되는 상황에서 가족과 의사는 의사결정능력이 없는 환자를 대신하여 의학적 근거, 예상되는 삶의 질, 환자라면 선택하였을 법한 환자에게 최선의 이 익이 되는 결정을 내려야 한다. 또한 맥락적 특성을 고려해야 하는데, 여기에서는 가족이 겪는 이해상 충에 대한 인지, 제도의 측면에서 연명의료결정법의 영향에 대해 논하였다. 의사와 가족은 함께하는 의 사결정(shared decision-making)을 통해 4분면 접근법의 분석 내용을 논의하고 환자의 최선의 이익 에 부합하는 선택을 할 수 있을 것이다.
Abstract
This article discusses the case of an elderly patient with a severe stroke for whom hemicraniectomy was proposed to lower intracranial pressure. Although patients in this situation can increase their chances of survival with hemicraniectomy, expected quality of life following the procedure remains uncertain. This case is analyzed using the four topics chart, which consists of medical indication, patient preference, quality of life, and contextual features. In relation to contextual features, the conflict of interest experienced by the family as caregivers and the influence of the Life-Sustaining Treatment Decision-making Act are discussed. It is argued that in order to make medical decisions that are in the patient’s best interest, shared decision-making between physicians and family members should be based on information obtained through the four topics chart.
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