本文係描述一位中年男性罹患肝癌的個案，曾因肝癌導致症狀困擾而多次門診治療，個案皆拒絕住院，此次因肝癌併肝性腦病變而自急診轉住院，住院期間個案確診為肝癌末期之身心靈照護經驗。筆者於2011年5月7日至21日護理期間，藉Gordon 十一項功能性健康型態評估模式，透過觀察、會談、身體評估及病歷查閱等方式收集資料，確認個案有營養狀態改變/少於身體需要、慢性疼痛、無望感及案妻有照顧者角色緊張等健康問題，經與個案及照顧者共同擬訂具個別性及整體性之護理計畫，包括透過深呼吸、音樂療法及精油按摩，協助減輕個案疼痛；經由增強自我照顧能力及提昇自我價值而降低無望感；運用營養評估確立營養攝取不足主因並給予飲食衛教，且照會營養師提供癌症飲食指導，以改善個案營養問題；評估到照顧者負荷問題後，提供照護技巧回覆示教並協調親屬分擔照顧，以降低照顧者角色緊張。筆者在護理過程中，除提供照顧知識及技能外，並給予個案及照顧者心理支持，扮演各部門間溝通橋樑，適時轉介安寧共同照護團隊，促使個案及照顧者能獲得完善及持續性照護。

　　This is a case study describing a middle-aged man with terminal Hepatocellular Carcinoma (HCC). The patient accepted several outpatient treatments for HCC, but refused to be hospitalized. This time, he was transferred from the emergency center to be hospitalized due to the combination of both HCC and Hepatic Encephalopathy. During his hospitalization, he was further diagnosed as a terminal HCC patient needing special physical and spiritual care. From May 7 to May 21, 2011, The authors used the Gordon’s 11 Functional Healthy Assessment Model, observation, interview, physical assessment, and anamnesis checking to collect data, and confirmed that case was suffering from various health problems, including imbalanced nutrition: less than body requirement, chronic pain, hopelessness, and caregiver role strain (shown by his spouse, the major caregiver). The authors, together with the subject and his caregiver, then drafted an individualized and holistic caring plan, including deep breathing, music therapy, and essential oil massage to reduce the pain. Also, the authors helped increase the subject’s self-care ability to enhance his self-esteem and reduce the sense of hopelessness. The nutritional problems were solved through nutritional assessment, as well as the cancer-dietary guidance provided by the nutritionist, finding out the major cause of malnutrition, and therefore providing a more balanced diet and health education. After evaluating the caregiver’s pressure and difficulties, the authors further provided care-taking techniques and coordinated the sharing of caring loading among the subject’s relatives to ease caregiver role strain. During the nursing process, in addition to offer care-taking knowledge and skills, the authors offered psychological support to both the subject and his caregivers, played the intermediary role among various departments, and timely introduced the subject to the palliative care team in order to give him and his caregivers a more comprehensive and persistent care. The strengthening of palliative-care training and the enrichment of hardware and software equipment were also recommended to an effort to offer the best caring quality in the future.