用糖治療 天邊孝子症候群

原來我們醫療上這熟悉的情景，早就有個專用名詞叫「來自加州的女兒症候群」Daughter from California Syndrome。當然，加州的醫師也很不服氣的說，他們遇到的是「來自芝加哥的女兒症候群」Daughter from Chicago Syndrome，還有說是來自紐約的。台灣南部的則是來自台北的（當然也有反過來的，這點不必再戰啦～），或有人說來自「澳洲」的…. 不一而足，個人認為林秀娟教授的說法比較貼切，叫「天邊孝子症候群」！

「天邊孝子症候群」除了給醫療團隊或原來照顧的家人困擾以外，也經常是推動「善終」的阻力。

化解的方式，個人就這個症候群的特徵，我想了一個口訣就是SUGAR［糖］，其逐條的處理，就是化解之道：

1. Surprised by the scale of deterioration　

被父母惡化的病況程度嚇到了

因為很久沒有回來看父母了，印象還是一直停留在她離開時，上一次見到的那位「健康」的父母，對於眼前「病危」、已不成人形的父母，自然無法接受。

這時候，需要告訴她，隨著年紀增加，父母已經歷經多少次住院、多少次病痛、多少疾病，一一的列出，並好好的告訴她，父母承受了多少痛苦！現在看到她回來，而且這麼孝順、還這麼有成就，「終於可以放心了」「父母也很累了，希望能夠平順的走完人生必經之路」。我們要協助她渡過「否認」期。

2. Unrealistic expectation

對醫療有不切實際的期待

因為內心的自責與愧疚，她對醫療總是有不切實際的期待，例如希望父母可以很快好起來，跟以前一樣可以行動、可以吃… 當然，這樣的期待，就是很「不實際」，就是要從第１、３點給它拉回來。

3. Guilty feeling

愧疚罪惡感

自責與愧疚是這個症候群最大的關鍵。因為出嫁到遠方、平日工作忙碌，無暇回來看父母。雖然都有照「廣告」上建議的，購買昂貴的雞精、麥片、維骨力…來代替她照顧父母，但是，這時候，總是會因為平日無法陪伴父母而自責與愧疚，而最好的方式就是「否認」現況與「把責任轉嫁到別人身上」。所以，我們要體諒她的責罵，實際上是反應她自己內心的不安與內疚。因此，解除她的內疚的最好方式，就是肯定她的付出！對！最好的一句話就是：「我沒看過像你這麼孝順的女兒！」、「住那麼遠，還那麼掛心父母，平日就花錢給他們這麼好的補品，現在還大老遠放下工作趕回來！」、「我都有聽你父母和家人提起過，你真的是很孝順，爸媽有你這麼一位孝順的女兒，一定也很欣慰…」，等她眼淚流下來之後，就可以接下去說「可是，人畢竟會老…」，把她拉回現實。挑剔與指責只是表示她關心，這一點一定要給予肯定！醫護人員也不必因此而生氣，或是教訓她平日就要孝順父母與陪伴等等…. 這些保證都不會是她想聽的！

4. Absent from life or care of the patient

在父母的生活或照顧中缺席

就是以上所說的，人無法陪在身邊，但是一直都有照「廣告」上建議的，購買昂貴的雞精、麥片、維骨力…來代替她照顧父母！也有定時寄錢回來請其他兄弟姐妹要好好照顧父母啊！要他們買最好的給父母！怎麼會照顧成現在這樣呢？（很多當人家媳婦的，對小姑這樣的指責應該不陌生吧？）

這時候，一定要在其他照顧者的面前，肯定其他們照顧的付出：「你嫂嫂也很用心在照顧，如果不是這麼用心，就不太可能活到這個時候，你知道嗎？這個病在家裡是很難照顧的，我沒看過像你嫂嫂照顧得這麼好的！」要記得，我們都是同一陣線的，都是一起要為病人好！如果嫂嫂不斷的被指責，她為了推責任，予頭就會指向醫療人員！我們對所有「有付出的人」的人都要給予肯定，但也要協助他們解除「內疚」，他們才不會不理性的把「內疚」轉換成對醫療人員的挑剔與不滿。同理她們、肯定她們、讓她們知道，我們是一起在為她們的父母努力治療，我們是同一陣線的！

5. Reassert role as an involved caregiver　

重申參與照顧決策的角色

她回來，就會重申對父母醫療的參與和主導權。「我希望用最好的藥，自費也沒關係。」這點絕對要配合，自費的白蛋白、營養品、敷料… 都是不錯的，自己帶的珍貴精油按摩，當然也很棒！讓她花點錢（這也是她唯一能做的），有助於解除她的內疚。通融她多一點時間的訪視與陪伴、讓她參與洗澡與照護，是給她一些補償的機會。（網友說這叫：「從天邊到身邊，把動口改動手」）當然，尊重她的意見，召開家庭會議，肯定大家的付出，也代替父母，感謝有她們這麼孝順子女，父母也會很放心的走上人生必經之路，最後將大伙拉回歸到病人的現實狀況來討論。（網友說這是「糖衣苦藥」，先以糖衣包裝，再來談苦藥，比較能吞得下去～）

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只要我們醫療人員，認同「天邊孝子」也是一種「孝順」，也應該給予肯定；同時，也看到他們行為的背後，其實是「內疚與自責」，就能協助他們化解歧見(他們都在愛病人的，只是方式不同看法角度不同)，尋求最大公約數(都是愛病人、都是為了病人好)，共同為病人做出，最符合病人意願的決定。

「天邊孝子症候群」是我在2015年寫的文章，很多人在流傳，也被偶像劇「實習醫師鬥格」引用在劇中的橋段。因為這篇文章，才開啟了我想出書的念頭～

In the ICU, it’s not uncommon for critically ill patients to suddenly have “dutiful children” who live far away appear on the scene. These individuals often criticize the medical team’s treatments and blame the family members who have been caring for the patient all along—siblings or in-laws—for “giving up.” Even when the patient is in the terminal stage, beyond the point of recovery, and the family has decided to let the elderly patient pass away peacefully, this newly arrived “dutiful daughter or son” insists on doing everything possible to save them. The result? The elderly patient ends up with tubes inserted all over their body, ribs fractured from CPR, and bleeding from multiple orifices, unable to pass away peacefully.

This familiar scenario in medical care has long had a term: the “Daughter from California Syndrome.” Doctors in California, however, argue they more commonly encounter the “Daughter from Chicago Syndrome” or the “Daughter from New York Syndrome.” In southern Taiwan, it’s the “Daughter from Taipei Syndrome” (although sometimes the reverse is also true—no need to argue further!). Others might refer to it as the “Daughter from Australia Syndrome.” Personally, I find Professor Hsiu-Chuan Lin’s term “Dutiful Child from Afar Syndrome” more apt.

The “Dutiful Child from Afar Syndrome” not only creates difficulties for medical teams and family caregivers but also often becomes a significant obstacle to achieving a peaceful passing for the patient.

To address this syndrome, I’ve devised an acronym based on its characteristics: SUGAR (糖). Each step corresponds to a resolution strategy:

1. Surprised by the scale of deterioration

The child is shocked by how much their parent’s condition has worsened.

Since they haven’t seen their parents in a long time, their mental image remains stuck on the “healthy” parent they saw last. Confronted with a critically ill, unrecognizable parent, they struggle to accept the reality.

In this case, it’s essential to gently explain how their parent’s condition has changed with age—how many hospitalizations, illnesses, and pains they’ve endured. Highlight the hardships their parent has faced, reassure them that their presence now brings comfort, and emphasize that their parent is tired and ready to peacefully complete life’s journey. Our goal here is to help them move past their denial.

2. Unrealistic expectations

They have unrealistic expectations of medical care.

Driven by guilt, they hope for a miraculous recovery, wishing their parent could quickly return to their previous state of health—able to move, eat, and live normally. These expectations are often unrealistic. Gently bring them back to reality by referring to points 1 and 3.

3. Guilty feelings

Guilt and self-blame are central to this syndrome.

Because they’ve been far away—married off, busy with work, or simply absent—they feel deep guilt for not being around to care for their parent. Even though they might have followed “advertised” advice to send expensive tonics, supplements, or other gifts, they still feel they’ve failed to fulfill their responsibilities. This guilt manifests as denial or a tendency to shift blame onto others.

We must acknowledge their emotions, recognizing that their criticism often reflects their inner turmoil. Affirm their efforts with statements like, “I’ve never seen such a devoted daughter,” or “Even living so far away, you’ve always cared deeply about your parents, sending them the best supplements and now rushing back despite your busy schedule.” Once they feel understood, they’ll usually start to cry, opening the door to a gentle conversation about reality.

4. Absent from the patient’s life or care

Their absence leads to criticism of those who’ve been caring for the patient.

They might question why siblings or in-laws allowed their parent’s condition to deteriorate, even though they regularly sent money and instructed them to provide the best care. This often causes tension among family members.

Here, it’s crucial to affirm the contributions of those who’ve been present: “Your sister-in-law has been incredibly dedicated; without her care, your parent wouldn’t have made it this far. This illness is extremely challenging to manage at home.” Affirming all caregivers helps prevent blame from being redirected toward the medical team.

5. Reasserting their role as an involved caregiver

They seek to reclaim their role in decision-making.

Their desire to “spare no expense” on treatments, supplements, or therapies stems from wanting to contribute. Allow them to take part, even if it’s symbolic—approve their suggestions for premium supplements, or let them massage their parent with essential oils. Encourage them to spend more time with their parent or help with care tasks. This gives them a sense of fulfillment and helps ease their guilt. Family meetings can also be organized to validate everyone’s contributions and refocus discussions on the patient’s current needs and realistic care goals.

If healthcare professionals recognize that even “dutiful children from afar” are expressing a form of filial piety, and if we acknowledge the guilt and self-blame behind their actions, we can help resolve conflicts. By finding common ground—that everyone loves the patient and wants what’s best for them—we can work together to make decisions that align with the patient’s wishes.

I originally wrote about “Dutiful Child from Afar Syndrome” in 2015. The article was widely shared and even featured in a scene of the drama Intern Doctors. It was this piece that inspired me to consider writing a book.

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