本文在描述以個案管理師角色，全程照護一位印尼籍瀕臨死亡之乳癌轉移女性之經驗。個案管理期間為2008年10月13日至2009年1月3日，運用會談、觀察、電訪進行資料收集，護理過程發現病人有「疼痛」、「健康尋求行為」及「死亡焦慮」等護理問題，筆者以個案管理師借入，聯繫多專科診療團隊介入，協助病人對西醫治療灰心之際，返院症狀控制以減輕疼痛，尊重病人對神佛符水的堅持，傾聽並鼓勵病人說出身處異國面對死亡的擔憂與焦慮，以及對要捨棄年幼兒女兒離式的愧疚。運用團隊力量協助病人與家屬參與治療決策，陪伴家屬調適哀傷歷程，並一同完成病人心願與滿足需要，讓病人在人生終末時獲得善終，期望將此個案管理經驗與護理專業者分享。

This article described the experience of a case manager being with a breast cancer patient who was
on the verge of dying to have Good-Death. The duration of the case management was from October
13th, 2008 to January 3th, 2009. Data was collected by applying face to face interviews, observations,
and phone-call interviews. The patient’s health care problems including pains, anxieties about dying and
anticipatory grieving in families were found during the nursing process. The author played the role as a
case manager during this period of time to help this patient. It included helping client go back to the
hospital to control symptoms with alleviating pains, listening and encouraging the client to speak out her
anxieties of death, and cooperating multi-specific teams to intervene, applying powers of the treatment
team to assist this patient and her families to participate the decision-making process. In addition,
accompanied families to adjust the grieving process, accomplished the patient’s wishes and needs. In the
very end, the author assisted the patient to have a good death at the end of her life. The experiences of
the case management could share with the nursing professionals to help patients dealing with these
similar situations.