坏消息的告知课件41.ppt

1、壞消息的告知1影片的兩個印象醫師還不如法師不要倚賴家屬來告知病情2臨床溝通技巧下學期授課進度表 日期 授課內容 3/05 課程介紹及特殊狀況的臨床溝通技巧 3/19 同理心與溝通技巧 3/26壞消息的告知：詮釋及體驗 4/16 困難病人：觀念認知及體驗 4/23 困難狀況（一）（video 上）4/30&5/07 演練（一）5/14 困難狀況（二）（video 下）5/21&6/04 演練（二）6/18 期末考試（筆試、演練）*希望可以安排到教學門診觀摩一次3壞消息的告知n有關告知壞消息的一些倫理議題n台上演練：n相關議題：錯誤的處理4一位門診的複診病人，上次因排便習慣改變而被安排大腸鏡檢查。

2、輪到他看診時有一位較年輕的女仕率先步入，並回頭吩咐兩個較年輕的男性：先陪爸在外頭等一下。然後就向你（門診醫師）說：家父（指病人）在上週檢查大腸，檢查的醫生說腸子裡長了一個瘤子，看來像是癌症，今天是來看切片的報告，請先告訴我結果。因為家父已經七十多歲，又有心臟病，我們全家都怕他受不了刺激，所以如果是癌症，千萬不能讓他知道。你在電腦上查得病理報告是：adenocarcinoma,well differentiated。你要怎麼說？教案壞消息的告知5要說慌嗎？6說謊的時機謊言：做錯事，怕有糾紛白色的謊言：怕壞消息會傷害到病人7為何壞消息會傷害到病人？消息實在太壞，怕病人受不了消息不是太壞，但病人太脆

3、弱了8說謊有好處嗎？留給病人一線希望與病魔搏鬥的力量減除心理的痛楚避免不幸事件的發生（殺人、自殺）至少可減少哭泣及失眠9說謊有壞處嗎？不知真相，難以作出決定失去珍惜餘生的機會：家人共聚、財產分配、達成心願病人與家屬間互相猜疑，雙方承受的壓力比知道真相時更大醫生本身也承受壓力：病情不易解釋、要不斷地圓謊謊言被拆穿時，醫病關係盡毀違反醫學倫理？違反醫事法規？10生命倫理四原則尊重自主不傷害行善公正11生命倫理四原則尊重自主：病人要作出醫療決定，所以要告知不傷害：告知有時會造成對病人的傷害，所以不應告知 行善：告知有時會對病人有益，所以應該告知 公正：應該人人都告知或人人都不告知12生命倫理四原則：

4、一個古老笑話從前有個小瓜呆父母外出叫他看門臨行告知若有人來訪時如何應對：債主找爸爸：到深山去向老和尚請示人生哲理外公找媽媽：去大姐家坐月子鄰居取山羊：牠在後花園吃草媬母看娃兒：她在等你幫她洗澡13生命倫理四原則從前有個小瓜呆父母外出叫他看門果然，那些人都來了：鄰居取山羊：到深山去向老和尚請示人生哲理媬母看娃兒：去大姐家坐月子債主找爸爸：牠在後花園吃草外公找媽媽：她在等你幫她洗澡14生命倫理四原則只有小瓜呆才會被此四原則所約束我們如能運用智慧，四原則就像是四件法寶15研究倫理七原則尊重自主不傷害行善公正保密真實誠實所以，不能說謊，包括白色的16凡事誠實容易嗎？有時候難以啟齒病人的反應難料家屬堅持

5、不誠實病人不願知真相？17一位主治醫師的告白I was 25 years old and working in an emergency department.A young boy was brought in with severe head injuries following a traffic accident.We tried to resuscitate him,but it was obviously useless.I had to go out and tell his parents.Id never told anyone before that their child

6、 was dead and didnt have a clue what to say.I just blurted it out and the mother started screaming I didnt know how to handle the situation.I just said Sorry and ran out of the room.I can still hear that womans screams.That was over 30 years ago and I dont think things are really much better in term

7、s of helping young doctors learn how to break bad news.18回顧剛才的案例 一位門診的複診病人，上次因排便習慣改變而被安排大腸鏡檢查。輪到他看診時有一位年約四十多的女仕率先步入，並回頭吩咐兩個較年輕的男性：先陪爸在外頭等一下。然後就向你（門診醫師）說：家父（指病人）在上週檢查大腸，檢查的醫生說腸子裡長了一個瘤子，看來像是癌症，今天是來看切片的報告，請先告訴我結果。因為家父已經七十多歲，又有心臟病，我們全家都怕他受不了刺激，所以如果是癌症，千萬不能讓他知道。你在電腦上查得病理報告是：adenocarcinoma 你要怎麼說？19壞消息的告知若

8、壞消息不經意地揭露，醫病皆輸病家：持續，不必要的苦痛、誤判誤斷醫生：挫折感溝通技巧訓練不足就不能適切地告知壞消息20告知壞消息的三種方法(Brewin 1991)因認為無論怎麼說病人都會難過，故呈現得直率及欠缺感情仁慈且悲傷，但沒有支持、鼓勵或希望善解人意、正向、機靈的保證及具備同理心 21The Third Way須有以病人為中心的理念，兼顧生理 心 理 社會層面要有充分的機會讓病人發問及互動，並了解他們的感受若錯估病人對獲悉壞消息的反應而對消息作不適切的剪裁，可導致更多的焦慮與不確定必須了解病人的背景22壞消息難以告知的理由訓練不足而不知如何獲知病家感受害怕遭受責備害怕場面失控不知如何處理

9、情緒害怕感受自己的情緒須面對死亡或重症的恐懼23被告知壞消息後的情緒反應驚惶而沉默憤怒不相信悲痛內疚歸咎他人24被告知壞消息後情緒反應的處理要容許病人哭病人對於臨哭不亂的醫生會有高度評價太常見的是醫生把流淚視同出血，想盡快停止第一個動作常是遞給病人紙巾較佳的處理方式是靜待病人哭泣 勿以牙還牙，以怒還怒此刻有情勝無情：冷漠比哭泣更糟25告知壞消息非緊急情況有充分時間準備必須不斷地注意病人的感受提供資訊及發問的時間可能的話不要給其他的事（如討論診療計畫）所干擾Hogbin and Fallowfield(1989)將“bad new”consultations 的錄音帶提供給病人：心情較不煩亂時再

10、聽、播給家人聽26告知壞消息的能力養成演練個人心智成長、人文素養27告知壞消息的考量要點充分的準備、合宜的場所、足夠的時間確認病家知悉談話的目的緊記：你所認為有希望的消息對病人而言就是壞消息（反之亦然）不要以為還會有人向病人解說儘量給予正面的訊息但要避免不正確的保證確定病人有充足的時間領悟安排追約談，給予輔導機構的電話和地址在接見下一個病人之前先檢視自己的感受28告知壞消息的“SPIKES”步驟(R.Buckman,1992)1.Setting：建立一個恰當的情境。提供一個保護病人隱私而舒適的場所，不受干擾的時間，與病人面對面平坐。依病人的意願，邀請其他重要相關親友在場。這一切都在於建立良好的

11、醫病關係。2.Patients Perception：探詢病人對自己病情的了解。譬如說：告訴我，您知道我們為什麼要做這些檢查？3.Patients Invitation：引導病人來詢問有關病情的細節。譬如說：要是檢驗結果都出來了，您要知道全部詳細的內容嗎？（不管什麼都要知道嗎？）4.Knowledge：提供知識與資訊給病人。提供資訊時，最好採漸進式分段給，並要不斷試探病人是否消化了他所得到的資訊，避免用醫學上的專業用辭。5.Empathize：要能發掘病人情緒的變化，進而表示同情。如：當病人哭泣時，說看來您並沒有預期這樣情況，或說這個結果一定讓您很難接受。6.Summary：最後，將所有的資訊

12、綜合，做一個摘要，並且經由與病人溝通，去達成一個治療或追蹤的方案。Buckman R.How to break bad news.Johns Hopkins Univ.Press,1992:65-97.Baile WF,et el,Cancer 2019;86(5):887-97.王金龍醫師29PIKESnSetting：建立一個恰當的情境n提供一個保護病人隱私而舒適的場所，不受干擾的時間，與病人面對面平坐n依病人的意願，邀請其他重要相關親友在場n這一切都在於建立良好的醫病關係 30S IKESnPatients Perception：探詢病人對自己病情的了解n譬如說：告訴我，您知道我們為什麼

13、要做這些檢查？31SP KESnPatients Invitation：引導病人來詢問有關病情的細節n譬如說：要是檢驗結果都出來了，您要知道全部詳細的內容嗎？（不管什麼都要知道嗎？）32SPIESnKnowledge：提供知識與資訊給病人n採漸進式，分段提供n要不斷試探病人是否能消化了n避免用醫學上的專業用辭 33SPIKSnEmpathize：要能發掘病人情緒的變化，進而表示同情，如：當病人哭泣時，說n看來您並沒有預期這樣情況n這個結果一定讓您很難接受 34SPIKEnSummary：n將所有的資訊綜合，做一個摘要n經由與病人溝通，去達成一個治療或追蹤的方案 35壞消息的告知n有關告知壞消息

14、的一些倫理議題n台上演練：n家屬n病人n相關議題：錯誤的處理36一位門診的複診病人，上次因排便習慣改變而被安排大腸鏡檢查。輪到他看診時有一位較年輕的女仕率先步入，並回頭吩咐兩個較年輕的男性：先陪爸在外頭等一下。然後就向你（門診醫師）說：家父（指病人）在上週檢查大腸，檢查的醫生說腸子裡長了一個瘤子，看來像是癌症，今天是來看切片的報告，請先告訴我結果。因為家父已經七十多歲，又有心臟病，我們全家都怕他受不了刺激，所以如果是癌症，千萬不能讓他知道。你在電腦上查得病理報告是：教案壞消息的告知37處理方式與家屬作具同理心的溝通運用SPIKES來解釋病情38與家屬作具同理心的溝通從對話中了解：家屬的要求理由

15、感受家屬的感受表達了解並肯定家屬的關切告知家屬為何要病人病情：尊重自主、診療需要告知SPIKES的方式並徵詢意見承諾陪伴與支持共同達成目標39一位門診的複診病人，上次因排便習慣改變而被安排大腸鏡檢查。輪到他看診你在電腦上查得病理報告是：教案壞消息的告知40SPIKE1.Setting：建立一個恰當的情境。提供一個保護病人隱私而舒適的場所，不受干擾的時間，與病人面對面平坐。依病人的意願，邀請其他重要相關親友在場。這一切都在於建立良好的醫病關係。2.Patients Perception：探詢病人對自己病情的了解。譬如說：告訴我，您知道我們為什麼要做這些檢查？3.Patients Invitati

16、on：引導病人來詢問有關病情的細節。譬如說：要是檢驗結果都出來了，您要知道全部詳細的內容嗎？（不管什麼都要知道嗎？）4.Knowledge：提供知識與資訊給病人。提供資訊時，最好採漸進式分段給，並要不斷試探病人是否消化了他所得到的資訊，避免用醫學上的專業用辭。5.Empathize：要能發掘病人情緒的變化，進而表示同情。如：當病人哭泣時，說看來您並沒有預期這樣情況，或說這個結果一定讓您很難接受。6.Summary：最後，將所有的資訊綜合，做一個摘要，並且經由與病人溝通，去達成一個治療或追蹤的方案。41壞消息的告知n有關告知壞消息的一些倫理議題n台上演練：n相關議題：錯誤的處理42錯 誤43美國

17、人怎樣看待錯誤？44Case 1An 18-month-old child presents to the clinic with a runny nose.Since she is otherwise well,the immunizations due at 18 months are administered.After she and her mother leave the clinic,you realize that the patient was in the clinic the week before and had also received immunizations

18、then.Should you tell the parents about your mistake?45Case 1The error is a trivial one.Aside from the discomfort of the unnecessary immunization,no harm has resulted.Nonetheless,an open and honest approach to errors is most appropriate.While the parents may be angry initially about the unnecessary i

19、njection,they will appreciate your candor.On the other hand,should they discover the error and believe you have been dishonest,their loss of trust will be significant.46Case 2A 3-month-old has been admitted to the hospital with a newly diagnosed ventricular septal defect.She is in early congestive h

20、eart failure and digoxin is indicated.After discussing the proper dose with the attending physician,you write an order for the drug.Thirty minutes later the baby vomits and then has a cardiac arrest and dies.You discover that in writing the digoxin order you misplaced the decimal point and the child

21、 got 10 times too much digoxin.What is your duty here?Will you get sued if you tell the truth?47Case 2This unfortunate event represents a serious error with profound implications for the patient and family.You owe this family an honest explanation.They need to hear you say that youre sorry.Any attem

22、pt to hide the details of the event would be dishonest,disrespectful,and wrong.Though a lawsuit may follow,these parents are less likely to litigate if you deal with them honestly and take responsibility for the error.48Case 3A 3-year-old presents to the emergency department.She was diagnosed with p

23、yelonephritis by her physician yesterday,treated with an intramuscular injection of antibiotic and sent home on an oral antibiotic.She is vomiting today and unable to keep the antibiotic down.As you prepare to admit her,you feel she should have been admitted yesterday.Should you tell the parents tha

24、t their physician made a mistake?How should you handle this disagreement?49Case 3The practice of medicine is not an exact science.Frequently physicians will disagree about what constitutes the most appropriate management in a given case.Often these are legitimate disagreements with more than one acc

25、eptable course of action.Simply because you would have managed a patient differently does not mean the other physician made a mistake.In this case,you may wish to discuss the case with the other physician and explain why you manage children with pyelonephritis differently.However,in situations where

26、 standard practice varies,the parents should not be told that a mistake has been made.50The Ellen Roche StoryEllen Roche was a healthy 24 year old lab technician at the Johns Hopkins(JH)Asthma Center.She volunteered to take part in an experiment to understand the natural defenses of healthy people a

27、gainst asthma.Roche was part of a group that inhaled hexamethonium,a drug which induced a mild asthma attack.Physicians stood by in case of complications and to measure how the subjects responded to the asthma attack.Within 24 hours of inhaling the drug,Roche had lost one-third of her lung capacity.

28、Within a month she was dead.51The consent form she signed warned of coughing,dizziness,and tightness in the chest,but not death.It called hexamethonium a medication although its approval by the FDA(as a treatment for high blood pressure)had been withdrawn in 1972.Dr.Alkis Togias,the director of the

29、experiment,apparently limited his hexamethonium research to one contemporary textbook and PubMed.The Ellen Roche Story52The use of hexamethonium in the 1950s to treat high blood pressure created an evidentiary trail revealing some disturbing risks.Several articles published in print journals during

30、the 1950s showed that hexamethonium could cause fatal lung inflammation.Unfortunately,PubMeds coverage starts in the mid-1960s.When the FDA withdrew its approval of hexamethonium in 1972,it cited the drugs substantial potential toxicity.Unfortunately,PubMed covers medical research,not FDA rulings.Th

31、e Ellen Roche Story53Ellen Roche died on June 2,and the Roche family has apparently not yet filed a lawsuit.However,JH still faced a serious sanction.On July 19 the federal Office for Human Research Protection(OHRP)suspended all JH research on human subjects.This halted 2,400+ongoing experiments wit

32、h 15,000+human subjects.The Ellen Roche Story54The disruption was administratively chaotic,devastating to research,and potentially grave for patients participating in experiments who suddenly found their medication withheld.Perhaps for this reason the OHRP lifted the suspension three days later,thou

33、gh with the requirement that experiments meet new safeguards.The Ellen Roche Story55錯誤 診療過程中無可避免發生錯誤的原因知識缺乏判斷錯誤資訊不詳環境惡劣睡眠不足時間太趕一時恍惚56醫師在倫理上是否有義務告知他們的病人有關醫療錯誤的資訊？醫師必須真誠地對待病人 包括在發生錯誤而導致病人遭受重大傷害時 57醫師該如何決定是否要告訴病人有關錯誤的事？一般而言，即使無關痛癢的錯誤也應告知任何不告知的決定，均需有倫理辯證 如醫師經辯證認為宜不告知，他的判斷應有其他醫師審查，最好提到倫理委員會討論醫師決定不告知，須準備好

34、為自己辯護 58告知錯誤會否令病人不再信任醫師和醫療體系？有些病人會在被告知發生錯誤時會對醫療體系失去信任許多病人會在被告知發生錯誤時會對醫師失去信任但幾乎所有病人都想知道這些資訊若病人覺得被蒙騙時失去信任會更嚴重許多59告知病人自己錯了會否有被告的風險？病人不太會對誠實認錯的醫師提出訴訟許多訴訟都是因為病人覺得沒有被告知真相訴訟常是病人想要知道真相的方法陪審團會對誠實的醫師有較善待的判決 60如何面對錯誤 誠實不告知要有理由訴訟：失去信任 誠實告知61看到他人做錯該怎麼辦？白巨塔財前五郎 vs.里見脩二 62看到他人做錯該怎麼辦？看到他人做錯的醫師有責任讓病人知道真相必須採用最少打擾的方式當

35、事人沒有告知真相，便應鼓勵他勇於承認如果當事人拒絕，便應判定事情的嚴重性是否要向上級或醫院報告，或直接告訴病人提報者有責任說明事實並確認有嚴重錯誤 63參考資料University of Washington School of Medicine：depts.washington.edu/bioethx/6465u$qZnVkShPdMaJ7F4C0z)w&s!pYmUjRfOcL9H6E3B+y(u%r#oWlTiQeNbJ8G5D1A-x*t$qYnVkSgPdMaI7F3C0z)v&s!pXmUjRfOcK9H6E2B+y(u%rZoWlThQeNbJ8G4D1A-w*t$qYnVjSg

36、PdLaI7F3C0y)v&s#pXmUiRfNcK9H5E2B+x(u$rZoWkThQeMbJ8G4D1z-w*t!qYnVjSgOdLaI6F3C0y)v%s#pXlUiRfNcK8H5E2A+x(u$rZnWkThPeMbJ7G4C1z-w&t!qYmVjRgOdL9I6F3B0y(v%s#oXlUiQfNcK8H5D2A+x*u$rZnWkShPeMaJ7G4C1z)w&t!pYmVjRgOcL9I6E3B0y(v%r#oXlTiQfNbK8G5D2A-x*u$qZnVkShPdMaJ7F4C1z)w&s!pYmUjRgOcL9H6E3B+y(v%r#oWlTiQeNbK8G5D1A

37、-x*t$qZnVkSgPdMaI7F4C0z)v&s!pXmUjRfOcK9H6E2B+y(u%r#oWlThQeNbJ8G5D1A-w*t$qYnVkSgPdLaI7F3C0z)v&s#pXmUiRfOcK9H5E2B+x(u%rZoWkThQeMbJ8G4D1z-w*XmUjRfOcL9H6E2B+y(u%r#oWlThQeNbJ8G5D1A-w*t$qYnVkSgPdLaI7F3C0z)v&s#pXmUiRfOcK9H5E2B+x(u%rZoWkThQeMbJ8G4D1A-w*t!qYnVjSgPdLaI6F3C0y)v&s#pXlUiRfNcK9H5E2A+x(u$rZoWkThPe

38、MbJ7G4D1z-w&t!qYmVjSgOdL9I6F3B0y)v%s#oXlUiQfNcK8H5E2A+x*u$rZnWkThPeMaJ7G4C1z-w&t!pYmVjRgOdL9I6E3B0y(v%s#oXlTiQfNbK8H5D2A-x*u$qZnWkShPdMaJ7F4C1z)w&t!pYmUjRgOcL9I6E3B+y(v%r#oXlTiQeNbK8G5D2A-x*t$qZnVkShPdMaI7F4C0z)w&s!pXmUjRfOcL9H6E2B+y(u%r#oWlTiQeNbJ8G5D1A-x*t$qYnVkSgPdMaI7F3C0z)v&s!pXmUiRfOcK9H6E2B+x

39、(u%rZoWlThQeMbJ8G4D1A-w*t!qYnVjSgPdLaI6F3C0y)v&s#pXmUiRfNcK9H5E2B+x(u$rZoWkThQeMbJ7G4D1z-w*t!qYmVjSgOdLaI6F3B0y)v%s#pXlUiQfNcK8H5E2A+x*u$rZnWkThPeMbJ7G4C1z-w&t!qYmVjRgOdL9I6F3B0y(v%s#oXlUiQfNbK8H5D2A+x*u$qZnWkShPeMaJ7F4C1z)w&t!pYmUjRgOcL9I6E3B+y(v%r#oXlTiQfNbK8G5D2A-x*u$qZnVkShPdMaJ7F4C0z)w&s!pYmUjR

40、fOcL9H6E3B+y(u%r#oWlTiQeNbJ8G5D1A-x*t$qYnVkSgPdMaI7F4C0z)v&s!pXmUjRfOcK9H6E2B+y(u%rZoWlThQeNbJ8G4D1A-w*t$qYnVjSgPdLaI7F3C0y)v#oWlTiQeNbJ8G5D1A-x*t$qZnVkSgPdMaI7F4C0z)v&s!pXmUjRfOcK9H6E2B+y(u%rZoWlThQeNbJ8G4D1A-w*t$qYnVjSgPdLaI7F3C0y)v&s#pXmUiRfOcK9H5E2B+x(u%rZoWkThQeMbJ8G4D1z-w*t!qYnVjSgOdLaI6F3C0y)

41、v%s#pXlUiRfNcK8H5E2A+x(u$rZnWkThPeMbJ7G4D1z-w&t!qYmVjSgOdL9I6F3B0y)v%s#oXlUiQfNcK8H5D2A+x*u$rZnWkShPeMaJ7G4C1z)w&t!pYmVjRgOcL9I6E3B0y(v%r#oXlTiQfNbK8H5D2A-x*u$qZnWkShPdMaJ7F4C1z)w&s!pYmUjRgOcL9H6E3B+y(v%r#oWlTiQeNbK8G5D1A-x*t$qZnVkSgPdMaI7F4C0z)w&s!pXmUjRfOcL9H6E2B+y(u%r#oWlThQeNbJ8G5D1A-w*t$qYnVkSg

42、PdLaI7F3C0z)v&s#pXmUiRfOcK9H5E2B+x(u%rZoWlThQeMbJ8G4D1A-w*t!qYnVjSgPdLaI6F3C0y)v&s#pXlUiRfNcK9H5E2A+x(u$rZoWkThPeMbJ7G4D1z-w&t!qYmVjSgOdL9I6F3B0y)v%s#pXlUiQfNcK8H5E2A+x*u$rZnWkThPeMaJ7G4C1z-w&t!pYmVjRgOdL9I6E3B0y(v%s#oXlTiQfNbK8H5D2A-x*u$qZnWkShPeMaJ7F4C1z)w&t!pYmQfNcK8H5E2A+x*u$rZnWkThPeMaJ7G4C1z-w

43、&t!pYmVjRgOdL9I6E3B0y(v%s#oXlTiQfNbK8H5D2A+x*u$qZnWkShPeMaJ7F4C1z)w&t!pYmUjRgOcL9I6E3B+y(v%r#oXlTiQeNbK8G5D2A-x*t$qZnVkShPdMaI7F4C0z)w&s!pYmUjRfOcL9H6E3B+y(u%r#oWlTiQeNbJ8G5D1A-x*t$qYnVkSgPdMaI7F3C0z)v&s!pXmUiRfOcK9H6E2B+x(u%rZoWlThQeNbJ8G4D1A-w*t$qYnVjSgPdLaI7F3C0y)v&s#pXmUiRfNcK9H5E2B+x(u$rZoWkThQ

44、eMbJ7G4D1z-w*t!qYmVjSgOdLaI6F3B0y)v%s#pXlUiRfNcK8H5E2A+x(u$rZnWkThPeMbJ7G4C1z-w&t!qYmVjRgOdL9I6F3B0y(v%s#oXlUiQfNbK8H5D2A+x*u$qZnWkShPeMaJ7G4C1z)w&t!pYmVjRgOcL9I6E3B0y(v%r#oXlTiQfNbK8G5D2A-x*u$qZnVkShPdMaJ7F4C0z)w&s!pYmUjRfOcL9H6E3B+y(u%r#oWlTiQeNbK8G5D1A-x*t$qZnVkSgPdMaI7F4C0z)voXlTiQfNbK8G5D2A-x*u

45、$qZnVkShPdMaJ7F4C0z)w&s!pYmUjRgOcL9H6E3B+y(v%r#oWlTiQeNbK8G5D1A-x*t$qZnVkSgPdMaI7F4C0z)v&s!pXmUjRfOcK9H6E2B+y(u%rZoWlThQeNbJ8G4D1A-w*t$qYnVkSgPdLaI7F3C0z)v&s#pXmUiRfOcK9H5E2B+x(u%rZoWkThQeMbJ8G4D1z-w*t!qYnVjSgOdLaI6F3C0y)v%s#pXlUiRfNcK9H5E2A+x(u$rZoWkThPeMbJ7G4D1z-w&t!qYmVjSgOdL9I6F3B0y)v%s#oXlUiQfN

46、cK8H5D2A+x*u$rZnWkShPeMaJ7G4C1z-w&t!pYmVjRgOdL9I6E3B0y(v%s#oXlTiQfNbK8H5D2A-x*u$qZnWkShPdMaJ7F4C1z)w&s!pYmUjRgOcL9H6E3B+y(v%r#oWlTiQeNbK8G5D2A-x*t$qZnVkShPdMaI7F4C0z)w&s!pXmUjRfOcL9H6E2B+y(u%r#oWlThQeNbJ8G5D1A-w*t$qYnVkSgPdLaI7F3C0z)v&s!pXmUiRfOcK9H6E2B+x(u%rZoWlThQeMbJ8G4D1A-w*t!qYnVjSgPdLaI6F3C0y)

47、v&s#pXlUeNbJ8G5D1A-w*t$qYnVkSgPdMaI7F3C0z)v&s!pXmUiRfOcK9H6E2B+x(u%rZoWlThQeMbJ8G4D1A-w*t!qYnVjSgPdLaI6F3C0y)v&s#pXlUiRfNcK9H5E2B+x(u$rZoWkThQeMbJ7G4D1z-w*t!qYmVjSgOdLaI6F3B0y)v%s#pXlUiQfNcK8H5E2A+x*u$rZnWkThPeMaJ7G4C1z-w&t!qYmVjRgOdL9I6F3B0y(v%s#oXlUiQfNbK8H5D2A+x*u$qZnWkShPeMaJ7F4C1z)w&t!pYmUjRgOc

48、L9I6E3B+y(v%r#oXlTiQeNbK8G5D2A-x*u$qZnVkShPdMaJ7F4C0z)w&s!pYmUjRfOcL9H6E3B+y(u%r#oWlTiQeNbJ8G5D1A-x*t$qYnVkSgPdMaI7F3C0z)v&s!pXmUjRfOcK9H6E2B+y(u%rZoWlThQeNbJ8G4D1A-w*t$qYnVjSgPdLaI7F3C0yr#oWlTiQeNbJ8G5D1A-x*t$qYnVkSgPdMaI7F4C0z)v&s!pXmUjRfOcK9H6E2B+y(u%rZoWlThQeNbJ8G4D1A-w*t$qYnVjSgPdLaI7F3C0y)v&s#

49、pXmUiRfNcK9H5E2B+x(u%rZoWkThQeMbJ8G4D1z-w*t!qYnVjSgOdLaI6F3C0y)v%s#pXlUiRfNcK8H5E2A+x(u$rZnWkThPeMbJ7G4C1z-w&t!qYmVjSgOdL9I6F3B0y)v%s#oXlUiQfNcK8H5D2A+x*u$rZnWkShPeMaJ7G4C1z)w&t!pYmVjRgOcL9I6E3B0y(v%r#oXlTiQfNbK8G5D2A-x*u$qZnWkShPdMaJ7F4C1z)w&s!pYmUjRgOcL9H6E3B+y(v%r#oWlTiQeNbK8G5D1A-x*t$qZnVkSgPdMa

50、I3B0y(v%s#oXlTiQfNbK8H5D2A-x*u$qZnWkShPdMaJ7F4C1z)w&s!pYmUjRgOcL9H6E3B+y(v%r#oWlTiQeNbK8G5D1A-x*t$qZnVkSgPdMaI7F4C0z)w&s!pXmUjRfOcL9H6E2B+y(u%r#oWlThQeNbJ8G5D1A-w*t$qYnVkSgPdLaI7F3C0z)v&s#pXmUiRfOcK9H5E2B+x(u%rZoWlThQeMbJ8G4D1A-w*t!qYnVjSgPdLaI6F3C0y)v&s#pXlUiRfNcK9H5E2A+x(u$rZoWkThPeMbJ7G4D1z-w&t!q