-1-

()

, ,

-2-

,

1

2

3

4

5

-3-

1)

, , , , , (holistic care)

1. ,

-4-

2)

WHO .

1. ,

.

.

.

.

, , .

-5-

3)

1. ,

Curative/remissive therapy

Presentation Death

Palliative Care Hospice

Relieving suffering

-6-

4)

1. ,

6

: , , ,

to alleviate(disease) withoutcuring

Hospice care is end of lifeoriented

Palliative care is goal oriented

-10-

1)

(WHO) :

: (), (), ,

:

(1989): ,

2.

-11-

2)

, (1968) 5 .

2.

(Denial)

(Anger)

(Bargaining)

(Depression)

(Acceptance)

(Hope)

-12-

3)

.

2.

, - () .

, .

, , .

, , , -

-13-

4)

Pattison(1974)

2.

,

,

,

,

,

,

,

,

-14-

1)

3.

2 .

, ,

.

-15-

1)

3.

6 .

- (, ) ,

- (, 6 .)

-16-

2) ()

3.

Medicare 6 .

Medicare , 36.5 . 15.6%7 , 14.9% 6 .

-17-

2) ()

3.

. .

, , .

-18-

3)

.

3.

, (, , , )

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4)

: .

3.

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5)

1 241 7 , .

3.

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1 24 1 7 . .

-21-

6)

1 . .

3.

() .( ) .( ) , .( ) .

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7)

3.

.

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7)

3.

:

:

: .

2001 2002

-24-

3.

() : . > , ,

: , , , .

(, Death with dignity): . .

-25-

3.

(, Euthanasia): .(active euthanasia) (physician assisted suicide)

(Advance Directive): . , , , .

: , ,

-26-

7)

3.

(Informed consent)

. .

(withholding) (withdrawing) , , , , .

(Futile Management)

.

-27-

7)

3.

(Do-Not-Attempt-Resuscitation, DNAR)

-28-

8)

3.

/

:

/

/

:

/

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9)

3.

.

.

.

.

. .

-30-

10)

3.

, , , .

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-31-

1)

4.

:

(%)

1 Pain 67(77.0)

2 Family coping 31(35.6)

3 Elimination: Bowel 22(25.3)

4 Psycho-spiritual distress 15(17.2)

5 Dyspnea 15(17.2)

6 Skin integrity 10(11.5)

(%)

7 Nausea, vomiting 9(10.3)

8 Ascites 8(9.2)

9 Edema 6(6.9)

10 Urinary problem 5(5.7)

11 Oral mucosal integrity 3(3.4)

: (2000). , 3(1), 60-74.

-32-

1)

4.

Twycross Model

(%)

(Somatic

source)

(Cancer) 47(54.0)

(Non cancer pathology) 42(48.3)

Symptom of debility 37(42.5)

(Side effect of therapy) 16(18.4)

-33-

4.

(%)

(Depression)

30(34.5)

(Sense of helplessness) 23(26.4)

23(26.4)

(Loneliness) 20(23.0)

12(13.8)

(Disfigurement) 8(9.2)

7(8.0)

7(8.0)

Twycross Model

-34-

4.

(%)

(Anger)

Anger with relationship* 14(16.0)

(Perceived neglect from family*)

12(13.8)

(Therapeutic failure) 9(10.3)

(Anger at God*) 3(3.4)

(Unavailable doctors) 1(1.1)

(Friends who do notvisit)

1(1.1)

Twycross Model

-35-

4.

(%)

(Anxiety)

(Fear of death) 34(39.0)

(Fear of pain) 30(34.5)

(Uncertainty aboutfuture)

27(31.0)

(Worry about family) 22(25.3)

(Spiritual unrest), (guilty) 17(19.5)

(Family finances) 14(16.0)

(Loss ofdignity and bodily control)

12(13.8)

(Fear of hospital) 1(1.1)

Twycross Model

-36-

4.

1)

,

- :, , , , ,

- : , , , , , , , ,

, ,

-37-

4.

1)

, , ,

: , ,

:

: , ,

-38-

4.

2)

(Needs) (Rights)

,

(honest answers)

,

,

, ,

,

,

. Victoria Hospice Society(2004) .Psychosocial care of the dying and bereaved.

-39-

4.

2)

, , ,

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4.

3)

. . . , ( ), , , .

, , . . , , .

-41-

5.

Degner (1991) 7 10 .

-42-

5.

Debratz(1990) 4

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,