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系統識別號 U0026-1007201208290900
論文名稱(中文) 哀傷的意義與癌末病人死亡前後照顧者哀傷撫慰需求
論文名稱(英文) The meaning of grief and the needs of grief counseling for care-givers, both before and after the death of terminally ill cancer patients
校院名稱 成功大學
系所名稱(中) 健康照護科學研究所
系所名稱(英) Institute of Allied Health Sciences
學年度 100
學期 2
出版年 101
研究生(中文) 賴維淑
研究生(英文) Wei-Shu Lai
學號 TA8931042
學位類別 博士
語文別 中文
論文頁數 320頁
口試委員 口試委員-曹朝榮
口試委員-賴明亮
口試委員-賴允亮
口試委員-陳清惠
口試委員-馮瑞鶯
指導教授-趙可式
中文關鍵字 哀傷  預期性哀傷  意義  癌末病人  哀傷撫慰  世代群組  哀傷連動性  詮釋學  前瞭解  詮釋循環  太極 
英文關鍵字 grief  anticipatory grief  meaning  terminally ill cancer patients  grief counseling  cohort  mutual grief  hermeneutics  pre-understanding  hermeneutic circle  Tai Chi 
學科別分類
中文摘要 哀傷會相互連動與影響,過去相關研究,大多是關注個體的哀傷,以病人為核心的關係網絡彼此之間所產生的哀傷連動性影響也不容忽視。本研究採「詮釋學(hermeneutics)」研究法,以癌末病人為核心所衍生出的「世代群組(cohort)」為研究對象,秉持詮釋學「整體」、「部分」與「前瞭解」、「本文」之間的「詮釋循環」,洞悉情境脈絡中哀傷的意義,並且同時關注個體間織籮緊密的互動關係對哀傷的連動影響。本研究從病人罹癌末期階段,直至病人去世後,持續追蹤陪伴哀慟者的哀傷歷程,以深度訪談、參與性觀察、錄音及田野記錄收集資料,經詮釋分析發現喪親者在哀傷處遇中擺盪於放手-不捨、穩定-脫序、渴念-閃躲、認-轉圜、分享-孤寂、凝聚-散伙、韌性-脆弱、盼望-絕望、昇華-淪陷、意義-苦難之間,相互消長並存,得中有失、失中有得,洞悉動態與矛盾中人實存的哀傷意義,與逝者情感連結越強,哀傷連動性越是矛盾掙扎。此研究進一步分析文本形成GRIEF哀傷撫慰需求,包含:善終/道別(Good-bye/Goodbye)、關係共融(Relational connectedness)、人-情境-脈絡中個別性哀傷反應(Individual reactions in person-situation-context)、情緒抒發(Emotional expression)、發現意義(Finding meaning)有助於哀傷苦難的超越。此外,醫療照顧者因貼近癌末病家的哀傷處遇,而擺盪於貼近-逃避、分享-孤寂、同感-麻木、滋養-勞瘁、意義-苦難的動態矛盾之間,藉由注視苦難看見自己、撫觸自己未完成的哀傷而能看見別人,在人性交會中相濡以沫,學習生與死,體會生命的意義感,豐富自己的生命,成為助人者行動背後之重要內在動力。
本研究結果發現「太極(Tai Chi)」哲理影響人對生命的認識與哀傷意義之詮釋,喪親者在癌末病人過世前所經歷的預期性哀傷,以及在病人去世後的哀傷反應為「開放式」的動態循環,而非封閉式的恆常,哀傷有著一段靈性躍升的轉化歷程,「並非」僅是被動地在生命的現實中調適,本研究所揭橥的哀傷動態意義和連動性,增加既有的哀傷知識體。因此,哀傷撫慰必須同時關注家庭整體所產生的哀傷連動性與當中個別性需求,從「人-情境-脈絡」之中洞悉哀傷的意義,方能瞭解個體的時空定位(temporal nature of a case),在同頻的時空向度之中展現「此時此刻(here and now)」的「共在(being with)」與提供「適人-適時-適境」之哀傷撫慰。
英文摘要 People’s grieves are mutually interconnected and interactive. In contrast to past studies taking an individual’s grief as the research topic, the impacts from mutual grief in a relational network based on patients as cores of research are not negligible. Holding the “hermeneutic circle” between “whole” and “part” or “pre-understanding” and “text” in hermeneutics, we chose “cohort” derived from terminally ill cancer patients as nuclear subjects of research in order to have insight to the meaning of grief in person-situation-context and mutual effects out of individuals’ close interactions on their grieves. In this study, we continuously accompanied and tracked grieved persons during their mournful courses from illness to death of terminally ill cancer patients by means of in-depth interview, participant observation, recording, and field survey for collections of data and found vicissitudes or coexistence of emotional volatility of the bereaved in grievous conditions, for instance, letting go vs. holding on, stability vs. disorder, yearning vs. dodge, yielding vs. mediation, sharing vs. loneness, cohesion vs. breakup, tenacity vs. frailty, hope vs. despair, sublimation vs. degradation, or meaning vs. suffering, each of which is as good lost as found. It can be seen from insight into people’s actually existing dynamic and conflicting grieves that the incompatible struggle is significantly observed in the bereaved with a strong emotional link to the deceased. In our further analyses about the needs of grief counseling, the following GRIEF conditions are of service to transcend from grief, i.e., good-death/goodbye, relational connectedness, individual reactions in person-situation-context, emotional expression, and finding meaning. In addition, the medical caregivers who stayed with grievous situations of terminally ill cancer patients’ family had dynamic contradictions including being with vs. evasion, sharing vs. loneness, sympathy vs. insensitivity, nourishment vs. exhaustion, or meaning vs. suffering, descrying not only themselves through other people’s sufferings but also other persons by consoling their own incomplete grieves, and helping one another in a humanistic rendezvous to learn living and death, experience implication of living, enrich their own lives, and achieve critical inner motivation supporting helpers’ actions.
In this study, we found the philosophy of Tai Chi has some effects on people’s hermeneutics for meanings of life and grief: both anticipatory grief and grief of the bereaved before and after the death of a terminally ill cancer patient are “open” dynamic recurrence rather than closed constancy; grief contains a transformation course in which there is spiritual elevation besides passive adaptation in real life; dynamic and mutual grief disclosed in this study promotes the existing grief-related knowledge body. As a result, grief counseling should pay close attention to both mutual grief generated in a whole family and individual demands of the family, so as to thoroughly understand the meaning of grief as well as temporal nature of a case in “person-situation-context” and display grief counseling featuring “being with” as well as “matching people, time, and circumstance” in the co-channel temporal dimension here and now.
論文目次 第一章 緒論…………………………………………………………………….…1
第一節 研究動機與重要性..................................1
一、本研究對臨床照護之價值.……………………………………………..…4
(一)填補醫療照護體系之缺口…………………………………………......4
(二)「見樹」與「見林」之哀傷撫慰…………………………………......5
(三)作為醫療專業人員在哀傷幽谷中之「共在(being with)」準備…..8
二、本研究對人的科學(human science)之反思………………………….8
(一)哀傷是種「病」嗎?...................................9
(二) 「走出?」或「走過?」哀傷…………………………………......10
三、本研究對知識體之建構…………………………………………………..11
(一) 建構哀傷的在地視野與哀傷撫慰服務模式…………………….....12
(二) 從詮釋中尋回哀傷處遇之主體性……………………………….....14
四、研究過程本身就是一種哀傷療癒………………………………………..13
(一)讓哀傷被看見,啟動療癒契機………………………………….…....15
(二)為苦難的附帶成長提供空間…………………………………….....…16
五、本研究對研究者本身之成長………………………………………….….15
(一)「由得看愚癡,由失看淨智」……………………………………...…17
(二)從受苦者身上學習,精鍊有品質的「共在(being with)」…… .18
六、民眾教育…………………………………………………………………..18
(一)哀傷的普遍性…………….…………………………………….…....18
(二)容許哀傷…………………………………………………………......20
第二節 相關概念操作性定義...............................22
(一)癌末病人(terminally ill cancer patient) ………….22
(二)逝者(deceased)…………………………………………………..22
(三)喪親者(bereaved)………………………………………………..22
(四)照顧者(care-givers)… ………………................22
(五)失落(loss)………………………………………………………...22
(六)喪親(lose a relative)…………………………………….….23
(七)哀傷(grief)……………………………………………………....23
(八)哀傷歷程(grieve)…………………………………………….....23
(九)預期性哀傷(anticipatory grief)…………………………..23
(十)哀傷撫慰(grief counseling)………………………………….23
(十一)居喪(mourning)……………………………………………....23
(十二)喪親狀態(bereavement)…………………………………..….23
(十三)喪親者的照顧(bereavement care)………………………...24
第三節 研究問題………………………….…………………………….…...25
第四節 研究目的…………………………………………………………………25
第二章 文獻查證……………………………………………………………...26
第一節 失落與哀傷…………………………….………………………….…26
第二節 哀傷的概念分析………………………………………………………31
第三節 常見的哀傷反應……………………………………………………….32
一、哀傷的連鎖反應…………………………………………………….…..32
二、哀傷反應--文獻評論……………………………………………….. .34
第四節 哀傷的內涵…………………………………………………………..36
一、記憶……………………………………………………………………...36
二、自我……………………………………………………………………...36
三、時間………………………………………………………………......37
四、空間………………………………………………………………….....37
五、想像與知覺…………………………………………………….…..…..38
六、關係………………………………………………………………..…...38
七、構築意義…………………………………………………………….....39
第五節 影響哀傷之要素……………………………………………………..42
一、哀傷表達的性別差異………………….……………………………....43
二、死亡形式 ………………………………………………………………...44
三、文化習俗對哀傷歷程之影響……………………………………………..46
四、其他相關因素………………………………………………………..……49
第六節 哀傷的週期與複雜性哀傷--醫療照顧者之角色 ………………….50
第七節 哀傷論述的演變與批判………………………………………………56
一、哀傷歷程階段論之批判…………………………..…………………….56
二、哀傷的醫學模式 (Medical models)與批判……………………….59
三、哀傷任務假設與批判………………………………………………..……62
(一)哀傷任務(grief work)介紹……………………………………..62
(二)哀傷理論之曲解與承襲………………………………………...…..62
(三)哀傷任務(grief work)所遭逢的現實挑戰………………….……64
第八節 哀傷之相關量表與批判……………………………………………..69
第九節 現有哀傷量性研究之裂缺與批判………………………………..…70
一、哀傷量性研究設計之問題…………………………………………….….70
二、脈絡因素相互關係影響研究之推論…………………………………....71
三、總結……………………………………………………………………....71
第十節 喪親對家庭之衝擊…………………………………………………….75
第十一節 當摯愛離去後之哀傷撫慰 ………………………………. ....77
第十二節 醫療照護者之哀傷……………………………………….......83
第十三節 從知識體裂缺導出研究方向…………………………..……..…86

第三章 方法論與研究方法………………………………………………...88
第一節 量性與質性研究之分野……………………………………......88
第二節 質性研究取向適合本研究之原因……………………………....89
第三節 各式質性研究法評析………………………………….………...90
(一)現象學………………………………………………………………..91
(二)民族誌………………………………………………………………..92
(三)紮根理論…………………………………………………………..…94
(四)符號互動論……………………………………………………….….96
(五)詮釋學………………………………………………………………..96
二、質性研究之特色…………………………………………………………102
三、依據研究旨趣選擇「詮釋學」之思考路徑剖析………………………102
第四節 研究方法與研究設計……………………………….….......104
一、詮釋學的源起與演進……………………….………………………….107
二、文本的融通~理解、解釋與詮釋………………………………………110
三、詮釋學核心內涵………………………………………………………..111
(一)反省「我」如何在詮釋中現身~前瞭解….…………………….…112
(二)讓動態與矛盾中人實存的意義得以浮現~詮釋循環…………..…113
(三)讀者與文本相遇~視域融合…………….…………………….….114
(四)“發現”與“意義”結構間之關係…………………………………116
(五)研究者與參與者的關係~生命的深度共享……………………..…117
(六)詮釋學研究過程就是護理的本質…………………………..….…119
第五節 研究對象……………………………………………………………120
第六節 收案流程………………………………………………………….122
第七節 研究工具……………………………………………………………123
第八節 資料收集方式……………………………………………………..125
一、深度訪談……………………………………………………………...125
二、參與式觀察及田野記錄……………………………………………...130
三、錄音方式………………………………………………………….…..131
第九節 倫理考量………………………………………………………...132
一、倫理原則之確保……………………………………………………...132
二、從知識與權利反思研究倫理、研究者與參與者之關係………….…135
三、檢視移情(transference)與反移情對哀傷撫慰陪伴歷程之影響…136
第十節 資料分析……………………………………………………………139
一、研究者的「前瞭解」反省報告…………………………………………139
二、 資料分析過程………………………………………………………..140
第十一節 研究嚴謹度之確保……………………………………………..143
一、方法論與研究方法之融通………………………………………….….143
二、研究品質之判準觀乎研究者之世界觀(Weltanschauung)……...144
三、研究嚴謹度確保之應用……………………………………………....145
(一)徵信度(credibility)...........................145
(二)適切度(fittingness)…………………………………......148
(三)稽核度(auditability)………………………………………..149
(四)確認度(confirmability)…………………………………...149
第四章 研究結果…………..……..………………...………………….151
第一節 研究對象描述………………………………………………………..152
第二節 前瞭解自我省察(self reflection)之反省報告………...160
第三節 研究結果………………………………………………………….…162
一、癌末病人「世代群組(cohort)」哀傷的意義…………….......163
二、癌末病人「世代群體(cohort)」哀傷的連動性影響……………..164
三、癌末病人喪親者哀傷撫慰需求………………………………………...167
四、醫療照護者哀傷的連動性與相互影響………………………………...168
五、「類別模型」(constitutive patterns)和主題(themes)呈現.169
第五章 討論…………..……………………………………....………..252
第一節 動態與矛盾中人實存的哀傷意義…………… ..………………….252
第二節 「世代群組(cohort)」之間哀傷的連動性與相互影響…………255
第三節 檢視哀傷論述西學中用之文化適用性………………………………256
第四節 宗教信仰、習俗禁忌與夢對哀傷之影響……........…………258
第五節 哀傷的附帶成長~哀傷的禮物(The gift of grief)………..262
一、回首向來蕭瑟處,也無風雨也無晴…………………………………….263
二、在「失去」中重新定義「擁有」.........................264
第六節「見樹」與「見林」之哀傷撫慰 …………………………….….266
一、最親近的陌生~家‧常是隱藏哀傷的………………………………..266
二、疲累也是哀傷的一部份………………………………………………..268
第七節 時間無法沖淡一切……………………………………………………270
一、哀傷的波動性………………………………………………….….…..270
二、與逝者情感連結之延續(continuing bonds)……………………………..271
第八節「死得其時,悲得其所,醫得其法」……………………..…….…273
一、好的臨終照護是哀傷撫慰的開始~(Goodbye=Good+bye)…….…273
二、本土性兒童安寧療護之需求與發展………………………….……..…275
第九節 檢視文化對哀傷的禁錮~順變難節哀……………………..…..…276
一、我不哭,不代表我不難過、我想哭,可是要找到「對」的人…………276
二、我已經失去了那麼多,為何我還要堅強………………………………..279
第十節 凝視憑藉與遮蔽--照顧者自身之撫慰(care for care-givers)281
第十一節 對護理診斷之再思…………………………………………………….284
第六章 結論與建議…………………………………………..…………………287
第一節 研究優勢與限制………………………………………………………..287
第二節 研究結果之應用與建議………………………………………….…….291
一、臨床實務之應用………………………………......………...291 (一)讓「在(presence)」的照護價值被彰顯……………………..…291
(二)洞悉哀傷的多元面貌與獨特需求………………………………….293
(三)超越語言力量的療癒……………………………………………….294
(四)因為忙碌,更需要療癒性的「共在(being with)」………..295
二、教育之應用……………………………………………………………..297
(一)醫療專業教育………………………………………..……….….…297
(二)民眾生命教育………………………………………………………..299
三、知識體系之未來研究應用…………………………………………….…299
四、國家醫療政策之建議…………………………………………………….300
參考文獻…………………………………………………………………....302

附件
附件一 人體試驗委員會審查通過證明…………………………………...314
附件二 受訪者同意書…………………………………………………..…315
附件三 受訪者基本資料(親友)………………………………….…………317
附件四 受訪者基本資料(醫療照護者)………………………………..….319
附件五 訪談指引…………………………………………………………....320

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