Foster Larry W, McLellan Linda J
Department of Social Work, Cleveland State University, OH 44115, USA.
Soc Work Health Care. 2002;35(3):37-51. doi: 10.1300/J010v35n03_03.
A large number of Americans would rather rely on family and friends more than their physicians about end-of-life care and decisions. Moving beyond traditional clinical ethics and its dyadic focus on the physician-patient relationship, this article presents an approach to ethical decision-making at the end of life that is more inclusive of the patient's family and has the potential to advance social work practice in end-of-life care. Initial attention is given to how psychosocial and bioethical perspectives and practices interact to shape understanding of moral issues in end-of-life decisions. Morally relevant principles are then adapted from contextual therapy as being useful for including more of a family focus and viewing ethical decision-making at the end of life as a family process. Specifically, focus is on exploring the ethical dynamics of family systems that impact the decision-making process and translating psychosocial insight into ethical discussions that are supportive of families. The case of a patient with sudden and unexpected brain death and without advance directives demonstrates one family's unresolved grief and illustrates how its members were helped to reason morally about end-of-life choices. Contributions of a social worker and bioethicist are illustrated.
许多美国人在临终护理和决策方面更愿意依赖家人和朋友，而非他们的医生。本文超越了传统临床伦理学及其对医患关系的二元关注，提出了一种临终伦理决策方法，这种方法更能包容患者的家人，并有潜力推动临终护理中的社会工作实践。首先关注的是心理社会视角和生物伦理视角及实践如何相互作用，以塑造对临终决策中道德问题的理解。然后，从情境疗法中借鉴道德相关原则，这些原则有助于更关注家庭，并将临终伦理决策视为一个家庭过程。具体而言，重点是探索影响决策过程的家庭系统的伦理动态，并将心理社会洞察力转化为支持家庭的伦理讨论。一名突发意外脑死亡且未立生前预嘱的患者的案例，展示了一个家庭未解决的悲痛，并说明了其成员是如何在道德层面上思考临终选择的。文中还阐述了一名社会工作者和一名生物伦理学家所做的贡献。
