台灣透析病人簽署不施行心肺復甦術（DNR）同意書之調查

Retrospective Study of Dialysis Patients' Do-not-Resuscitate (DNR) Consent in Taiwan

馬瑞菊(Jui-Chu Ma) ； 楊春紀(Chun-Chi Yun) ； 林佩璇(Pei-Xuan Lin) ； 林淑茹(Su-Lu Lin) ； 蕭嘉瑩(Chia-Ying Hsiao) ； 郭豐吉(Fen-Gji Gu) ； 蘇珉一(Min-I Su)

《台灣醫學》 22卷3期 (2018/05) Pp. 232-241

https://doi.org/10.6320/FJM.201805_22(3).0002

摘要

為探討透析中心常規透析病人安寧療護之現況，本研究採電子病歷回溯性調查設計，以透析中心2011年1月1日至2015年12月31日(共5年)常規透析個案進行分析。透析病人共412位，平均年齡為63.2歲(SD = 14.4)，平均透析月數為58.8 (SD=53.5)月，生活功能中有54.9%需依賴他人照顧，預立醫療指示簽署比率為1.2%，DNR簽署比率為9.9%；收案5年中透析病人死亡率為19.9%，而平均DNR簽署距離死亡之時間為56.46(SD=133.9)小時，在死亡之82位病人中其猝死比率為25.6%，死亡前仍接受CPR比率者為12.2%，絕大部分病人臨終前仍接受透析治療，僅有5人(6.1%)在死亡前撤除透析治療，常規透析病人年齡普遍較大且超過五成需依賴他人照顧；死亡率為19.9%，並有25.6%之透析病人猝死，但預立醫療指示及DNR簽署比率皆較低，因此醫療人員必須儘早與病人及家屬討論預立醫療自主計畫及死亡之議題，對於進入到生命末期之透析病人須循序漸進地給予緩和醫療資訊並充分溝通持續透析或终止透析之必要性，方能避免無效醫療，圓滿病人善終的自主心願。

關鍵字

透析病人 ； 不施行心肺復甦術 ； 預立醫療自主計畫 ； 撤除透析治療 ； 緩和醫療

並列摘要

To investigate the current status of palliative care for regular dialysis patients in dialysis center, this is a retrospective investigation collecting regular dialysis patients’ electronic medical records between January, 2011 to December 31, 2015. There were 412 dialysis patients with an average age of 63.2 years (SD = 14.4 years). The mean length of time on dialysis was 58.8 months (SD = 53.5 months). 54.9% of the patients had partial or complete dependence in activity of daily living. The percentage of signing advance medical directive was 1.2%, and of signing Do-not-resuscitate(DNR) consent was 9.9% of the patients. The mortality was 19.9% in the 5-year dialysis cases, and the mean interval between DNR orders to death was only 56.46 hours (SD = 133.9 hours). Among the 82 dead patients, the percentage of sudden death was 25.6%, and 12.2% of them still experienced cardiopulmonary resuscitation before death. Most of the patients still received dialysis before the death, and only 5 (6.1%) stopped dialysis before the death. Regular dialysis patients are generally older and more than 50% of them are dependent in activities of daily living. These vulnerable patients had high mortality (19.9%) and high sudden death rate, but the percentage of advance directive and DNR orders was low. Therefore, medical personnel must discuss with the patients and their families about the issue of advance care planning and death To avoid non-beneficial treatment on dialysis patients entering the end of life, we should provide the information of palliative treatment to them in a gradual and orderly approach and keep exploring the necessity of continuing or terminating dialysis.

並列關鍵字

dalysis patients ； do-not-resuscitate ； advance care planning ； withdrawal from dialysis ； palliative care

參考文獻

林慧美、楊嘉玲、陳美妙等：住院病人簽屬預立醫療指示的意願及接受宣導的意向。安寧療護雜誌2011;16:281-95。[Lin HM, Yang CL, Chen MM, et al: Inpatients' Willingness on and Acceptance of Promotion for Signing of Advance Directives. Taiwan Journal of Hospice Palliative Care 2011;16:281-95.]

林妙穎、羅月雲、黃秀美等：末期腎病病人之預立醫療計畫。安寧療護雜誌 2010;15:331-41。 [Lin MY, Luo YY, Huang HM, et al: Advance Care Planning Discussions for Patients with End Stage Renal Disease. Taiwan Journal of Hospice Palliative Care 2010;15:331-41.]

陳淑雅 、胡文郁、楊郁 等：從安寧緩和療護視角揭露血液透析病人對末期疾病預立醫療計畫的看法。安寧療護雜誌 2010;15:269-89。[Chen SY, Hu WY, Yang YU, et al: Explore to Perspectives of Advance Care Planning of End-of-Disease in Patients with Hemodialysis: From View of Hospice Palliative Care. Taiwan Journal of Hospice Palliative Care 2010;15:269-89.]

吳春桂、蘇玲華、黃勝堅等：DNR之情告知與決策對於重症生命末期照護之重要性。安寧療護雜誌 2009;14:172-85。[Wu CK, Su LH, Huang SJ, et al: I Discussion and Decision Making of DNR Issue is Important in End-of-Life Care for the Critically Ill. Taiwan Journal of Hospice Palliative Care 2009;14:172-85.]

姚建安、邱泰源、陳慶餘：末期腎臟疾病的安寧緩和醫療。安寧療護雜誌 2007;12:321-31。 [Yao CA, Chiu TY, Chen CY, et al: Palliative Care For End Stage Renal Disease. Taiwan Journal of Hospice Palliative Care 2010;15:331-41.]