探索重症單位癌症病人醫療代理人決策衝突之決定因子:混合性研究法

Explore of Decision-Conflict Among Surrogate of Cancer Patient in Intensive Care Unit: Mmixed-Methods Research

孫婉娜(Wan-Na Sun)

指導教授 ： 許心恬

高雄醫學大學/護理學院/護理學系碩士班/碩士(2018年)

摘要

背景：本研究主要在探討重症單位癌症病人醫療代理人在醫療決策過程中，易造成決策衝突的因素及過程中的經驗歷程。方法：透過質量性混合研究法，分兩階段進行，採方便取樣，在南部某醫學中心成人重症單位進行收案，以年滿20歲者且代理入住重症單位癌症病人之醫療決策者為對象，第一階段為採橫斷性、預測性量化研究，採結構性問卷在病人入、出重症單位的三天內進行兩次資料收集；第二階段為質性研究，採取現象學研究法進行，透過深度訪談及內容分析來探索醫療代理人決策過程的經驗歷程。結果：在量化研究中共納入115位醫療代理人，當中以女性（57.4%）、已婚（70.4%）、有工作（64.3%）、教育程度為大學以上（47.8%），且與病人關係以長輩為主（31.3%）為主。研究結果發現醫療代理人年齡(r=.278, p=.003)、壓力(r=.290, p<.01)與決策衝突有正相關，而醫療成員支持度(r=- .363, p<.01)則與決策衝突呈現負相關，採逐步複回歸分析計算出個變數對決策衝突解釋變異量各為年齡(sr2=5%)、壓力(sr2=8%)及醫療成員支持(sr2=16%)，整體總解釋變異量為29%。質性訪談醫療代理人醫療決策歷程，共納入八位醫療代理人，透過文本脈絡共歸納出四大主題〝用愛抗衡：靜謐的嘶?O〞、〝擇愛困境：鐵門內失格〞、〝讓愛蔓延：天使走過人間〞及〝窒愛難行：連體嬰悲歌〞。前兩大主題因重症單位有會客時間限制，迫使醫療代理人無法隨侍於病人旁，醫療代理人對於醫療診治方向及成效不安的揣測、懸心及猜疑，加上病人因使用高精密儀器及管路下，讓身體外觀明顯改變，醫療代理人所面對的衝擊遠超過想像；第三大主題為華人文化特有，因華人對於愛、情感的傾訴是內斂且含蓄的，家人伴侶之間關係的牽動更為複雜且深具含意，當中不論是正向抑或消極的情感連結，都牽引著醫療代理人決策過程當中實際的感受；第四大主題為醫療代理人決策過程當中，衝突的來源及感受當中包含因決策後的預後及改變難以衡量及想像，加上與醫療團隊溝通及知識上的落差以及手足間的責任、罪惡感的拉扯，而導致在決策過程中所產生的衝突。結論：醫療代理人在醫療知識及資訊相對不足之下，卻需要協助摯愛決擇醫療處置，身、心同時承受莫大壓力是無人能體會，故醫療代理人易在此時與醫療團隊之間關係緊繃，醫療團隊可針對高衝突族群提供適切且足夠的支持，並淺顯說明醫療處置方針及主動提供彈性會客時間，可降低醫療代理人在決策過程中之衝擊及負向感受。

關鍵字

重症單位 ； 癌症 ； 醫療代理人 ； 決策衝突 ； 混合性研究

並列摘要

Background: This study primarily discusses the decision making process for medical agents of cancer patients in the intensive care unit, the factors that can easily cause conflict to the decision making, and the experience of this process.
Methods: The study was performed using a mixed qualitative and quantitative research method, divided into two stages, with convenience sampling, in an adult intensive care unit of a medical center in southern Taiwan. Sample were medical decision makers at least 20 years old, and are medical agents of cancer patients admitted into the intensive care unit. The first stage was a cross-sectional, predictive quantitative research, and data collection was performed twice via structured questionnaires given to the patients within three days of entering and exiting the intensive care unit. The second stage was a qualitative research with a phenomenological approach, exploring the medical agents’ experience of the decision making process through deep interviews and content analysis.
Results: A total of 115 surrogates were enrolled for the quantitative study, with most agents being female(57.4%), married(70.4%), employed(64.3%), have an education level of university(47.8%) and above, and are seniors of the patients(31.3%). The study results found that the age(r=0.278, p=0.003) and stress (r=0.290, p<0.01) of surrogates showed a positive correlation with decision conflicts, while the degree of support from medical staff showed a negative correlation with(r=-0.363, p<0.01) decision conflicts. Stepwise multiple regression analysis was used to calculate explained variation of the decision conflict making by each of the variables of age (sr2=5%), stress (sr2=8%), and medical staff support (sr2=16%) from medical personnel, and the total variance explained was 29%.A total of 8 surrogates were included for qualitative interviews on the medical decision-making process. Based on the context of this paper, a total of 4 major themes were classified: “Use love to resist: a quiet scream”, “Dilemmas with love: Disqualification behind bars”, “Allow love to spread: An angel among us” and Suffocating love, “difficult decision: Conjoined twin’s elegy”. The reason for the first two themes comes from visitor time restrictions in the ICU, disallowing surrogates to stay by the side of the patient. The agent’s restless speculations, worries, and suspicions towards the direction of medical treatment and treatment effectiveness, in addition to the use of high precision equipment and tubing on the patient resulting in significant changes in physical appearance, can cause unimaginable impact faced by surrogates. The third major theme is unique to the Chinese culture. This is because expressions of love and emotions in Chinese people are restrained and implicit. Affected relationships between family members and spouses are complex and have profound meaning. Regardless of optimistic or pessimistic emotional connections, these feelings all affect the actual feelings of surrogates during the decision-making process. The fourth theme talks about how during the instance of the surrogate’s decision making process, the source and feelings of conflict include the difficulty to measure or imagine the prognosis and change after making the decision, in addition to the gap in communication and knowledge with the medical team and the war between the responsibility of a sibling and guilt, causing conflict to emerge during the decision making process.
Conclusion: Surrogates are required to assist in determining medical treatments for their loved ones under circumstances where their medical knowledge and information are relatively insufficient. The enormous physical and mental stress burdened on them cannot be understood by others. Therefore, there tends to exist a tense relationship between surrogates and the medical team during these situations. The medical team can provide appropriate and sufficient support for high-conflict populations, briefly explain the treatment regimen, and proactively provide flexible visitor timings. This can decrease the impact and negative feelings felt by surrogates during the decision-making process.

並列關鍵字

Intensive Care Unit ； cancer patient ； surrogate ； decisional conflict ； mixed methods

參考文獻

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