一位88歲患有末期失智症及嚴重吞嚥困難的女性因吸入性肺炎入院（BMI 14.2）。醫師建議放置餵食管。病患的女兒（被法定任命為醫療代理權人 DPOA）拒絕，理由是病患生前曾表達不願接受人工餵食。剛從外州趕來的兒子強烈要求立刻放置餵食管，大吼：「你們這是在眼睜睜看著我媽餓死！」護理師的首要處置為何？
An 88-year-old female with terminal dementia and severe dysphagia is admitted for aspiration pneumonia (BMI 14.2). The provider recommends a feeding tube. The patient's daughter, the legally appointed Durable Power of Attorney for Healthcare (DPOA), refuses, citing the patient's prior wishes against artificial feeding. A son arriving from out of state demands immediate placement of a feeding tube, shouting, "You're letting my mother starve to death!" What is the nurse's priority action?
- AAsk the provider to insert a temporary nasogastric tube to appease the son until the conflict is resolved.請醫師插入臨時鼻胃管以安撫兒子，直到衝突解決。
- BInform both family members that artificial feeding is always contraindicated in terminal dementia anyway.告知雙方家屬，人工餵食在末期失智症中始終是禁忌。
- CExplain to the son that the daughter's legal designation as DPOA overrides his demands.✓ 正解向兒子解釋，女兒被指定為醫療代理人（DPOA）的身份凌駕於他的要求之上。
- DRefer the family conflict to the hospital ethics committee for an immediate interdisciplinary meeting.將家庭衝突轉介至醫院倫理委員會進行即時的跨學科會議。
本題探討醫療倫理的預設醫療指示與代理決策權。根據 NCSBN 規範，具有持久醫療授權書（Durable Power of Attorney, DPOA）的人擁有專屬的法律權力，得代替無能力決策的病患行使自主權（Autonomy）。當家屬之間發生衝突時，醫療團隊必須在法律上優先遵從 DPOA 的決定，因為她的決定代表了病患生前的意願。選項A擅自放置餵食管侵犯了病患的自主權且構成醫療侵權（Battery）。選項D雖然照會倫理委員會是良好的後續溝通手段，但當下的首要行動是清楚確立決策的合法層級，即告知兒子 DPOA 的權限高於其他親屬。選項B在醫學上不完全正確，雖然失智末期常不建議插管，但並非絕對禁忌症（absolute contraindication），重點仍在於尊重病患意願的法定程序。
This question addresses the medical ethics of advance directives and surrogate decision-making. According to NCSBN standards, the holder of a Durable Power of Attorney for Healthcare (DPOA) has exclusive legal authority to exercise the patient's autonomy on behalf of an incapacitated patient. When family conflict arises, the medical team must legally defer to the DPOA's decision, as her decision represents the patient's previously expressed wishes. Option A, placing a feeding tube without authorization, violates patient autonomy and constitutes medical battery. Option D: although referring the case to the ethics committee is a sound follow-up communication strategy, the immediate priority is to clearly establish the legal hierarchy of decision-making, namely informing the son that the DPOA's authority supersedes that of other relatives. Option B is not entirely medically accurate; although tube feeding is often not recommended in end-stage dementia, it is not an absolute contraindication, and the focus remains on the legal process of respecting the patient's wishes.
美國非常強調 DPOA (持久醫療授權書) 的個人絕對代理權；在台灣，雖有《病人自主權利法》，但在實務操作上受到傳統家庭倫理影響，醫師常會要求「全體家屬取得共識」才敢拔管或拒絕治療，兒子的抗議在台灣往往會讓團隊暫停動作並安排家庭會議。