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  • 學位論文

癌末死亡病人簽署不施行心肺復甦時點與醫療利用之相關性研究

The association between timing of Do-Not-Resuscitation decision and Health care utilization among cancer decedents

指導教授 : 林文德

摘要


前言:本國安寧緩和醫療條例已立法十餘年,文獻指出2000~2006年癌症末期病人死亡前一個月接受CPR(Cardiopulmonary Resuscitation 心肺復甦術)比率雖有逐年下降趨勢,但至今仍有許多癌症末期病人簽署DNR(Do Not Resuscitate 不施行心肺復甦術)的時間過晚,造成不適當的醫療介入與醫療費用增加。本研究目的即以台灣南部某一區域教學醫院為例,初步探討癌症末期病人簽署DNR的時點分布情形,及其對最後一次住院醫療利用的影響。 方法:採回溯性次級資料分析的研究設計,蒐集南部某區域教學醫院2009年1月1日至2013年6月30日期間癌症死亡病人最後一次住院病歷資料,排除14位未簽署DNR,將已簽署者共473位納為研究對象,其中分為住院前簽署(N=181)、住院當天簽署(N=114)及住院後簽署(N=178)。三種簽署時點病人間之人口學特性、疾病特性、住院型態等以卡方檢定其差異;簽署天數、住院天數與住院費用,則以Kruskal-Wallis test檢定其差異,最後以羅吉斯迴歸模型及對數轉換(logarithm transformation)模型分析簽署時點與醫療利用的相關性。結果:人口學特性男性以住院當天簽署,女性為住院前簽署佔多數。簽署時點與婚姻狀況達顯著相關(p<0.01),癌症別與癌症期別無差異。三組入院地點顯著以急診入院佔最高(p<0.001),入院主訴以呼吸困難明顯多於其他症狀(p<0.001)。住院後簽署其鴉片類止痛劑與牧靈關懷利用明顯少於住院前簽署;而在超音波、抗生素、電腦斷層等利用高於住院前簽署。影響醫療利用的因子有簽署時點、性別、年齡、教育程度、癌症期別、癌症別。 結論:癌末死亡病人在最後一次的住院中仍有約1/3的比例為晚期簽署DNR,此晚期簽署有較大的機會增加侵入性醫療及費用,為提升臨終品質,未來應鼓勵儘早與癌症末期病患及家屬進行簽署DNR的溝通與教育。

關鍵字

簽署時點 DNR 醫療利用

並列摘要


Introduction:Although the ratio of terminal cancer patients who received CPR (Cardiopulmonary Resuscitation) within the last month of their lives were declining annually since the Hospice Palliative Care Regulation had been established more than a decade ago, the aggressiveness in end-of-life care may not reduce accordingly due to late DNR (Do Not Resuscitate) decision. This study aimed to investigate the timing of DNR decision and its impact on the health care utilization of last hospitalization based on the data from a metropolitan teaching hospital in southern Taiwan. Methodology:We retrospectively retrieved chart data for cancer decedents who died between January 1st 2009 and June 30th 2013. After excluding 14 cancer decedents who did not sign up DNR and those who hospitalized less than 3 days, this study collected 473 cancer decedents who had signed DNR as our sample subjects. According to the timing of their DNR decision, they were classified into three groups: before admission DNR(N=181), admission DNR(N=114), post admission DNR(N=178). Among three groups, their demographical characteristics, disease categories and utilization of various intervention were compared by Chi-Square test; while their living days after signing DNR, lengths of stay in the hospital and medical expenditure were compared by Kruskal-Wallis test; Finally, the association between the timing of DNR decision and utilization of various intervention was analyzed by logistic regression models, while the association between the timing of DNR decision and medical expenditure was analyzed by multiple regression models with logarithm transformation on expenditure. Results: Screened from the demographic data, most of the male signed DNR on the day of admission DNR and most the female before admission DNR . On the relationship between the timing of DNR decision and marriage, the married ones became significant (p<0.01). There are no variance found, considering from the kinds and stages of the cancer on the patients. Admission to the emergency room is the highest place of obvious(p<0.001),The most patient complained was dyspnea((p<0.001). Post admission DNR of opioid analgesics and pastoral care utilization were significantly less than the before admission DNR(p<0.05) ,but the computed tomography(p<0.001) and antibiotics (p<0.05)were relatively more utilized. The timing of DNR decision were relevant (p<0.001) with the lengths of stay , periods after DNR decision and medical expenditure among those cancer decedents. The factors, which affected health care utilization, are the timing of DNR decision, sex, age, education, cancer stages and cancer kinds. Conclusion: More than 1/3 of cancer decedents made DNR decision late in their last hospitalization and that may result in more aggressive medical intervention and higher medical expenditure. To improve end-of-life quality care, policy to promote early DNR decision may be warranted

參考文獻


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