本文之目的係運用安寧療護所強調之全人、全家、全程與全隊的理念於一位癌末且困難出院病人之出院準備服務，協助其順利出院並能得到持續性照顧直至平安往生。護理期間自96年7月5至25日，確立造成病人困難出院的問題如下：一、全人面向包括症狀未獲控制，令病人家屬對出院缺乏安全感、案主不被瞭解的孤獨和家中照顧人力與支持系統不足；二、全家面向包括決策關鍵者不明且意見紛歧與案兄照顧負荷過重而身心俱疲；三、全程面向為欠缺適切且持續性的安寧療護計畫；以及四、全隊面向為家屬對醫療處置缺乏信任，導致醫病關係的緊張。再則針對病人量身訂做之持續性照護計畫如下：一、全人照顧著重於協助症狀控制，增進病人舒適與鼓勵情緒表達並同理其感受；二、全家照顧則為確認決策關鍵者與案主之重要他人、同理案兄的照顧負荷，提供實質援助與召開家庭會議，凝聚照顧共識；三、全程照顧為協助轉介安寧居家照顧及後續哀傷撫慰；以及四、全隊照顧包括團隊各司其職，提供全方位照顧與團隊藉此經驗反躬自省進行檢討。最終，病人順利出院並於一星期後平安往生。筆者期待此出院準備經驗之分享有助於臨床實務發展出以家庭為中心和四全觀點之跨專業持續性出院計畫。

Whole person, family-centered, continued care, and multidisciplinary approach were four core values of hospice palliative care applied in this paper to assist in the diffcult processes of discharging termi-
nal cancer patients from the hospital and providing continued care until their peaceful death. Reasons underlying difficulties with discharges identified during hospitalizations between July 5th to 25th
2007 include: 1. ‘whole person’ aspects, including lack of confdence with the discharge on the part of the patient and his / her families due to inadequate symptoms control and loneliness due to lack of caregiver understanding and support; 2. ‘family-centered’ aspects, including failure to designate a key decision maker, differences of opinions, and overwhelming caregiver burdens; 3. ‘continuity of care’ aspects, including lack of appropriate and continuing palliative care and 4. ‘multidisciplinary
approach’ aspects, including factitious relationships among patient, family members, and healthcare providers due to lack of trust. Furthermore, the healthcare team mapped out individual and continued
care plans as follows: 1. ‘whole person’ aspects should focus on symptom control, enhancing comfort, and encouraging emotional expression; 2. ‘family-centered’ care aspects should identify the key per-
son and signifcant others, decrease caregiver burdens, provide essential assistance and conduct family conferences; 3. ‘continuity care’ aspects should include consulting hospice home care and bereave-
ment care professionals; 4. ‘multidisciplinary approach’ aspects should address comprehensive care so that team members learn from and refect on their experiences. Ultimately, patients were successfully
discharged from the hospital and peacefully passed away one week afterward. The writer hopes this nursing experience will provide a valuable reference for clinical practice to develop a family-centered
approach to palliative care based on the four core values of hospice palliative care and the multidisci-plinary discharge plan for terminal cancer patients.