「劇情電影」姊姊的守護者

罹患白血病的女兒凱特：蘇菲亞瓦希麗娃
身為律師的母親莎拉：卡麥蓉迪亞
因醫學科技誕生的妹妹安娜：艾碧貝絲琳
幫安娜辯護的律師：亞歷鮑德溫
消防員也是孩子們的爸爸的布萊恩：傑森派屈克

電影中的姐姐罹患的就是白血病，當然在疾病的描述上不是電影的重點，主要探討的還是生命、親情、倫理道德。

In the movie, the older sister suffers from leukemia. While the film doesn't delve deeply into the medical details of the disease, its primary focus is on exploring themes of life, family, and ethics.

急性淋巴白血病也稱為急性淋巴母細胞性白血病（acute lymphoblastic leukemia, ALL）是兒童最常見的白血病，白血病細胞起源於淋巴前體細胞，最有效的之鑑別診斷方式是骨髓抽吸檢查

Acute lymphoblastic leukemia (ALL), also known as acute lymphocytic leukemia, is the most common type of leukemia in children. The leukemic cells in ALL originate from lymphoid progenitor cells. Bone marrow aspiration is the most effective diagnostic method.

急性骨髓性白血病（AML）：主要發生於骨髓細胞，常見於成人，白血病細胞起源於骨髓前體細胞。

Acute myeloid leukemia (AML) primarily originates from myeloid progenitor cells in the bone marrow and is more common in adults.

ALL 的預後通常比 AML 好。

The prognosis of ALL is generally better than that of AML.

在治療期間，白血球的數量可能會較低，通常會有一些護理指導，像是白血球小於 1000/mm2，建議少量多餐禁食生食

During treatment, your white blood cell count may be low. We will provide you with some care instructions. For example, if your white blood cell count drops below 1000/mm3, we recommend eating small, frequent meals and avoiding raw food.

完全緩解代表治療後，身體內的白血病細胞數量大幅減少，且骨髓功能恢復正常。

Complete remission means that the number of leukemia cells in the body has been significantly reduced following treatment, and bone marrow function has returned to normal.

骨髓內芽細胞（blast cell）＜5%、無器官浸潤、造血細胞接近正常值 都是完全緩解的重要指標。

Less than 5% blast cells in the bone marrow, no organ infiltration, and near-normal hematopoiesis are all important indicators of complete remission.

周邊血液有芽細胞，則表示白血病細胞仍存在於血液中，不符合完全緩解的定義。

The presence of blast cells in peripheral blood indicates that leukemia cells still exist in the bloodstream, which does not meet the definition of complete remission.

腫瘤溶解症候群

腫瘤溶解症候群（Tumor Lysis Syndrome, TLS）是一種嚴重的代謝性併發症，通常發生在腫瘤細胞數量龐大且生長迅速的癌症患者，例如急性淋巴性白血病（ALL）和急性骨髓性白血病（AML）患者。當這些腫瘤細胞在治療（如化學治療）下快速死亡時，細胞內大量的核酸和其他物質會釋放到血液中。這些物質經由身體代謝後，產生大量的尿酸、磷酸鹽和鉀離子等，若身體來不及處理這些物質，就可能導致高尿酸血症、高磷血症、高鉀血症等，甚至引起急性腎損傷。

腫瘤溶解症候群與血糖無直接關聯： TLS 主要涉及的是細胞內物質的快速釋放，導致電解質紊亂和腎功能損傷。血糖的變化並非TLS的典型表現。

腫瘤溶解症候群的風險因子

腫瘤負擔大： 腫瘤細胞數量多。

腫瘤細胞生長迅速： 腫瘤生長速度快。

高敏感性腫瘤： 對化療等治療反應強烈。

腎功能不全： 腎臟無法有效排除代謝產物。

腫瘤溶解症候群的症狀

疲倦

噁心嘔吐

肌肉痙攣

呼吸困難

心律不整

尿量減少或無尿

腫瘤溶解症候群的預防

積極的水合治療： 在治療前和治療期間，增加水分攝取，幫助身體稀釋和排出代謝產物。

藥物治療：

Allopurinol： 是一種黃嘌呤氧化酶抑制劑，可以抑制尿酸的生成。

Rasburicase： 是一種尿酸氧化酶，可以將尿酸轉化為溶解度較高的尿酸鹽，從而降低血中尿酸濃度。

以上兩種藥物都可用於 ALL 和 AML 患者。 只要是接受化療，且有發生 TLS 風險的患者，都可以考慮使用。

靜脈輸液加入碳酸氫鈉： 鹼化尿液，促進尿酸排泄。

密切監測： 血鉀、血磷、尿酸、鈣離子等電解質的變化，以及腎功能的指標（如肌酐）。

姊姊的守護者

這個星期二和妹妹一起去看了姊姊的守護者…
這是一部感人足以讓電影院充滿擤鼻涕聲的電影。

沒看過書只看了預告的朋友。
可能會覺得這是部採人工基因的小朋友對父母的控訴…
但其實她是一個癌末病人的心聲。
面對癌症。
有些人是努力和上天爭取時間，抱著希望自己能夠走下去，
他們還是希望自己某一天可以站起來。
回復他們曾經擁有卻失去的生活。
『我會加油…我還要去當志工，我要感謝菩薩對我的眷顧…』
這是一個癌細胞已轉移，無法下床，全身水腫的病人告訴我的…
我到現在還是印象深刻。
至今，快要兩年了…不知道她是否還抱著同樣積極的想法…

但是有些人是能接受死亡，反倒是家人不顧一切的想要挽救生命。
像是片中的主角就是如此…
她是一個善解人意的姊姊。
她是一個默默在守護家庭的孩子。
雖然她失去了她的哥哥妹妹們的快樂生活。
但他不怨天不怨誰，反倒是能勇敢的面對死亡…
甚至到最後能說服了堅持的媽媽…

生命中有喜有悲，迎接新生兒的到來，但迎接一個摯親的離去，就也會帶來很大的痛苦。

也就是因為生命的有始有終，讓我們能學會珍惜與接受。

在護理照護中有一門課為臨終護理，它敘述著如何照顧將面臨死亡的病患，以及面對死亡的病患時，應如何照護。

在這部分的照護裡相當的強調尊重與病人的舒適。

醫療再也不是優先...

Life is full of joys and sorrows. While welcoming the arrival of a newborn brings immense happiness, bidding farewell to a loved one can cause profound grief.

It is precisely this cycle of life and death that teaches us to cherish and accept.

In the realm of nursing care, there exists a specialized field known as palliative care. This discipline focuses on providing compassionate care to patients facing the end of life, ensuring their comfort and dignity during this delicate time.

Respect and patient comfort are paramount in palliative care.

Medical intervention is no longer the primary focus...

人工基因被創造出來的小孩。
是為了疼愛，還是為了另一個生命所創造的…?
她依附她維生?還是能夠有獨自的想法?

影片最後她爭取到了…

這部影片我想很明顯的表示出。
這些小孩雖然年紀小，但卻明確的知道自己想要的或是不要的。
父母雖仍可左右其選擇，但卻無法改變小孩的想法。

我想這部片將在未來，會納入護理科系的教學影片吧XD
然後會要未來的護理科系學弟妹。
寫一篇有關臨終照護的心得：P
仔細想想，如果自己是癌症末期病人會有什麼選擇呢?
每個人的答案也許都有所不同…

但我倒希望如果是我能舒服的走，而不要經過太多次的醫療處置…
而你呢?

其實即將臨終的病人會有些瀕死症狀：

Terminally ill patients often exhibit various signs and symptoms that indicate their impending death. These symptoms can include:

呼吸會改變逐漸變淺短，甚至有可能暫停或張口呼吸(最常見的症狀)

Breathing becomes increasingly shallow and irregular, with possible pauses or the adoption of mouth breathing (the most common symptom).

出現咽喉肌肉無力將聚集喉後部的口腔分泌物咳出或因肺部分泌物增加，於呼氣時發出痰音般的嘎嘎聲；

Due to weakened throat muscles, patients may have difficulty clearing secretions from the back of their throat. Alternatively, increased lung secretions can produce rattling sounds during exhalation.

意識往往會不清楚；

Patients often experience a decline in consciousness.

因血液循環變差，皮膚有可能呈現濕冷、紫斑發紺現象，手部脈搏會逐漸變弱甚至摸不到。

As circulation worsens, the skin may become cold and clammy, develop purple spots, or appear bluish in the extremities. Hand pulses may gradually weaken or become undetectable.

眼神可能會呆滯、雙眼凹陷、光反射消失以及鞏膜水腫

Eyes may become vacant, sunken, and unresponsive to light. Conjunctival edema may also occur.

會有吞嚥困難(最常見的症狀)、噁心嘔吐、腹脹、大小便失禁情形(肛門括約肌可能會放鬆)

Swallowing difficulties (a common symptom), nausea, vomiting, abdominal bloating, and incontinence (due to possible relaxation of the anal sphincter) may be observed.

另外臨床上說的奇異脈（paradoxical pulse）是指在吸氣時，病人橈動脈搏搏動增強，在呼氣時搏搏動減弱或消失。奇異脈是心臟瓣膜病變的徵兆，並不是臨終病人的瀕死症狀。

It is important to note that paradoxical pulse, a condition characterized by a stronger radial pulse during inhalation and a weaker or absent pulse during exhalation, is not a symptom of imminent death. Rather, it is a sign of heart valve disease.

補充：死亡後的生理變化

死亡後，人體會發生一系列的變化，例如：

屍斑

血液循環停止後，血液沉積在身體低位部位形成的紫紅色斑塊。約在死後2小時左右開始出現，隨著時間推移，顏色會變得更深、範圍更廣。受到壓迫的部位由於血液循環受阻，反而不容易形成屍斑。屍斑通常會出現在身體的低位部位和未受壓迫的部位。

Rigor Mortis: The Stiffening of Death

人體在死亡後，肌肉會經歷一個從鬆弛到僵硬再到鬆弛的變化過程，這個現象稱為「屍僵」。屍僵是判斷死亡時間的重要指標之一。

Upon death, the human body undergoes a process known as rigor mortis, where the muscles stiffen. This process is a crucial indicator in determining the time of death.

屍僵的發生過程
Process of Rigor Mortis

死亡初期： 肌肉處於鬆弛狀態，身體各部位軟弱無力。

屍僵期： 隨著時間推移，肌肉內的ATP（三磷酸腺苷）耗盡，肌纖蛋白發生交聯，導致肌肉逐漸僵硬。這個過程通常從小肌肉群開始，例如眼瞼、下顎等，然後逐漸擴散到大肌肉群。

屍僵消退期： 屍僵的持續時間因人而異，通常在24-48小時內達到高峰，之後肌肉會逐漸鬆弛，恢復到軟弱無力的狀態。

Initially, the muscles become flaccid. As time passes, ATP (adenosine triphosphate) within the muscles depletes, causing muscle fibers to cross-link and stiffen. This process typically begins in smaller muscle groups such as the eyelids and jaw, gradually spreading to larger muscle groups. The duration of rigor mortis can vary, but it generally peaks within 24-48 hours before subsiding.

影響屍僵的因素

Factors Affecting Rigor Mortis

溫度： 低溫環境下，屍僵發生較慢，持續時間較長；高溫環境下，屍僵發生較快，持續時間較短。

Temperature: Lower temperatures slow down the process, while higher temperatures accelerate it.

身體活動量： 生前體力消耗越大，屍僵發生越快。

Physical Activity: Individuals with higher levels of physical activity prior to death tend to experience rigor mortis more rapidly.

死亡原因： 某些疾病或中毒可能影響屍僵的發生和發展。

Cause of Death: Certain diseases or poisoning can affect the onset and progression of rigor mortis.

臨終關懷

臨終關懷講求的是讓病人舒適的面對死亡，心理支持佔多數層面，而面對臨終，也有一些護理技巧需學習。

Palliative Care: Embracing Comfort and Psychological Support in End-of-Life Care

然而面對沒有意識，長期使用呼吸器被動式呼吸的病人也有相關準則規定

關於衛生福利部2012年公告的「腦死判定準則」，病人應符合下列先決條件：

According to the "Guidelines for Brain Death Determination" promulgated by the Ministry of Health and Welfare in 2012, a patient must meet the following prerequisites for brain death to be declared:

陷入昏迷指數為5或小於5之深度昏迷，且須依賴人工呼吸器維持呼吸。

Deep Coma: The patient must be in a deep coma with a Glasgow Coma Scale (GCS) score of 5 or less, and must rely on a ventilator for breathing.

昏迷原因已經確定。但因新陳代謝障礙、藥物中毒影響未消除前或體溫低於攝氏三十五度所致之可逆性昏迷，不得進行。

Established Cause of Coma: The cause of the coma must be definitively established. Brain death cannot be declared in cases of reversible coma due to metabolic disturbances, drug intoxication, or hypothermia (body temperature below 35°C).

遭受無法復原之腦部結構損壞。

Irreversible Brain Structural Damage: The patient must have irreversible structural damage to the brain.

清潔遺體(Postmortem Cleaning)

遺體護理的目的是維持遺體的尊嚴和整潔，並防止腐敗。

The purpose of mortuary care is to preserve the dignity and cleanliness of the deceased's body, and to prevent decomposition.

遺體的尊嚴和整潔，避免做出任何不尊重的行為。應保持遺體的清潔，並為其穿戴整齊。

t is crucial to treat the deceased with utmost respect and dignity, avoiding any actions that could be considered disrespectful. The body should be kept clean and dressed appropriately.

且應採取措施防止遺體腐敗，例如保持遺體涼爽乾燥。

Measures should be taken to prevent the decomposition of the body, such as maintaining a cool and dry environment.

為了防止胃內容物流出，造成污染，需協助鼻胃管留置病人反抽胃內容物後，再移除管路。

To prevent gastric contents from leaking out and causing contamination, it is necessary to assist the patient with nasogastric tube placement, aspirate gastric contents,

為了保持口腔的清潔和衛生，應協助遺體口腔護理後，並幫助閉合。

To maintain oral hygiene and sanitation, assist with postmortem oral care and help with closure.

為了防止尿液流出，造成污染，所以拔除留置導尿管前，宜先抽出水囊內蒸餾水再移除

To prevent urine leakage and contamination, the distilled water in the balloon should be removed before removing the indwelling catheter.

但不可移除頭部枕頭，會導致遺體的頭頸部變形，應將遺體放置在平坦的床上，並用枕頭墊高頭部和頸部，以保持其自然的曲度。

The head pillow should not be removed, as this could cause deformation of the head and neck of the deceased. The body should be placed on a flat bed, and a pillow should be used to support the head and neck to maintain their natural curvature.

覆蓋遺體：床單或毛毯覆蓋遺體

Covering the deceased: Drape a sheet or blanket over the body.

在護理工作面對病人的死亡，也是有一套護理流程，讓病人可以舒適的走完這一生，也可以帶給家屬心靈上的安慰。

In the face of patient death, nursing care has a set of protocols to ensure a comfortable end of life for the patient and provide emotional support for their loved ones.