血液透析之末期腎病併多重器官衰竭之病人，退出血液透析的影響因素探討－質性比較分析法

What Makes Doctors Suggest Withholding Hemodialysis Treatment for Patients with end-stage Renal Disease and Multiple Organ Failure? A Qualitative Comparative Analysis

張必正(Bih-Jeng Chang) ； 陳端容(Duan-Rung Chen) ； 吳寬墩(Kwan-Dun Wu)

《台灣公共衛生雜誌》 30卷4期 (2011/08) Pp. 362-371

https://doi.org/10.6288/TJPH2011-30-04-06

摘要

目標：2003年起，台灣末期腎病的發生率與盛行率皆為世界第一。全民健保施行後，有更多重症病人接受洗腎，即使病情不樂觀，仍不願放棄治療。本研究希望了解醫師建議病人退出透析的原因，及當醫師建議退出透析後，病人／家屬同意與否的因素。方法：8位腎臟科與急重症專科醫師提供末期腎病個案，並接受訪談。共蒐集31例。利用QCA(Qualitative Comparative Analysis)研究法進行質性資料分析。結果：『無法積極治療』是醫師建議退出透析最重要的必要條件。當『家人對治療的信念不一致』，即使醫師建議退出，家屬仍會拒絕。『年齡不大且透析時間長』是另一個意見不同的原因。結論：如果家屬間對治療的信念一致，而且醫師判定為「病患年齡大、情緒不佳、且預後不佳」時，醫師會建議退出透析，家屬多能接受。當家屬間對治療的信念不一致，醫師實需強化醫病溝通，建議退出透析，易引起爭議，不易提升末期照護品質。

關鍵字

QCA研究 ； 質性研究 ； 撤除透析 ； 末期腎病 ； 末期照護

並列摘要

Objectives: The incidence and prevalence of End-Stage Renal Disease (ESRD) in Taiwan have ranked first in the world since 2003. Under National Health Insurance, more ESRD patients with severe multiple organ failure undergo hemodialysis (HD) without regard to the quality of end-of-life. The purposes of this study were: first, to examine the conditions for which doctors would suggest that their patients consider withholding HD; second, to examine the conditions for which doctors had suggested that their patients consider withholding HD but the patients' families declined. Methods: Eight nephrologists and ICU specialists were asked to provide detailed information about their ESRD patients without revealing their names or other identifying data. Thirty-one clinical cases were collected. The Qualitative Comparative Analysis (QCA) method was employed to analyze the qualitative data. Results: The crucial factor associated with a doctor's suggestion to withhold HD was that the treatment would not be effective. When there were family disputes, the families would decline doctors' suggestions to withhold HD. Young age with a long duration of dialysis was another factor in disagreement. Conclusions: When a patient suffered from emotional problems, was in critical condition, was aged and there were no family disputes, then patients and doctors could agree on withholding HD for a better quality end-of-life. Given the same conditions, yet with family disputes, shared decision-making is recommended to reach consensus and preserve a better quality of life.

並列關鍵字

qualitative comparative analysis ； qualitative research ； withhold hemodialysis ； End-Stage renal disease ； End-of-Life care

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