從一位下肢裂傷的病患談告知後同意及拒絕治療權-高雄醫學.pptVIP

從一位下肢裂傷的病患談告知後同意及拒絕治療權 高雄醫學大學附設中和紀念醫院 急診部外傷科 郭良基 病患簡介 病人基本資料 Name: 陳x南 Gender: male Age: 40 years old Chart number:Arrival time: 94/12/12 12:40PM Referral from: 市立小港醫院 AM10:00, Dec. 12, 2005, 被機器捲入，意識喪失。 AM10:30, 被送至小港醫院急診室。 1. left distal tibia-fibular open fracture 2. right thigh crushing injury with traumatic above-knee amputation 3. right hand crushing injury 4. multiple abrasion and laceration AM10:46, Dec. 12, 2005 PM 12:41, Dec. 12, 2005 Airway: On endotracheal tube (7.5 Fr, fix 22cm) Breathing: RR : on vantilator, rate:16, FiO2:100% Circulation: HR: 70/min BP: 108/67 mmHg BT: 32.3C Skin: pale, cold and dry Disability: GCS: E1VTM1 Exposure: Right AK amputation, left distal T-F open fracture, right hand crushing injury, multiple abrasion and laceration Emergent operation Right lower extremity traumatic amputation → debridement + AK amputation I/O: 6000/380 pRBC 12U, FFP 12U Post-op on PM15:40, Dec. 12, 2005 PRBC 8U, PLT: 12U, FFP: 8U Levophed 2vial in 250cc keep 24gtt/min AM9:00, Dec. 13, 2005 HR: 152 RR:24 BT: 38.8 BP: unstable, hypotension : 70/40 Whole blood 2U + PLT 36U AM9:30, Dec. 13, 2005 HR: 140 RR:22 BT: 37.6 BP: 75/60 GCS: E1VTM4 PRBC 4U + FFP 8U Gelofusion 2 bot CXR, abdominal CT PM16:00, Dec. 13, 2005 HR: 152 RR:22 BT: 38.4 PM 23:30, Dec. 13, 2005 PRBC 3U + FFP 12U Dopamin 4 amp + 250cc D5W keep 10gtt Dec. 14, 2005 HR: 136 RR:20 BT: 36.8 BP: 91/40 unstable PRBC 2U + PLT 24U Foul odor of wound → arrange debridement PM15:00, Dec. 14, 2005 HR: 110↓ RR:20 BT: under 35C BP: 80/30 unstable, drop No urine output PRBC 3U + FFP 12U Gelofusion and dopamin use PM19:00, Dec. 14, 2005 HR: 60↓ , no BP Sign DNR by family Keep Gelofusion and Bosmin use Expired at 7:55PM 告知後同意法則（Informed consent doctrine） 1957年 Salgo v. Leland Stanford Junior University Board of Trustees 提出Informed consent 確認醫師有說明的義務及責任。 1960年 「最核心的揭露事項」是醫療處置的可能不良後果。 Mitchell v. Robinson 法院只主張必須揭露風險。 Natanson v. Kline 進一步