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不施行心肺復甦術(DNR)在內科加護病房氣切病人之現況分析

A Study of Do-Not-Resuscitate (DNR) among Patients with Tracheostomy in Medical Intensive Care Unit (MICU)

摘要


研究目的:探討加護病房中施行氣切病人其不施行心肺復甦術(DNR)之現況分析。材料與方法:採電子病歷回溯性調查設計,以2013 年8 月1 日至2015 年12 月31 日(共2 年5 個月)內科加護病房氣切病人進行分析。結果:氣切病人共112 位,平均年齡為71.1 歲(SD = 15.2)、所有的病人皆無健保IC 卡DNR 註記,收案之29 個月期間病人重複入院平均次數為4.3 次(SD = 3.6)、重複入ICU 平均次數為3.3 次(SD = 3.3)、醫療支出平均為417551.0 (SD = 367455.4)元。其中在本院執行氣切手術的103 位病人氣切手術同意書皆由家屬簽立,有30 位病人(佔29.1%)曾接受醫療人員DNR 意願諮商,但僅有12 位(佔11.7%)是在執行氣切手術前進行諮商,而有DNR 意願諮商組召開家庭會議的比率顯著高於未DNR 意願諮商組 (30% vs. 6.8%;P = 0.002)。在存活出院之99 位病人中平均年齡為70.8 歲(SD = 15.3),出院時昏迷或是意識不清者有48 人(佔48.5%),壓瘡者共31 人(27.7%),出院時所有的病人(100%)都須臥床及依賴他人照顧且幾乎所有病人都需要24 小時氧療及呼吸器使用 (N = 95;96%),其中又以下轉至呼吸照護病房安置者居多(N = 42;42.4%)。結論:內科加護病房氣切病人多為老年且都由家屬決定氣切手術,因此建議醫療人員對於清醒病人須尊重其醫療自主權。對於意識不清且須完全依賴照顧之病人,醫療團隊應召開家庭會議完整告知其後續照護與醫療現狀,且須宣導生命的延續不等於生活品質的確保之觀念。在醫療措施的抉擇上,應站在病人的角色切身的思考,並提供停止無效醫療之選項。

並列摘要


Purpose: to analyze Do-Not-Resuscitate (DNR) among patients with Tracheostomy in Medical Intensive Care Unit (MICU). Materials and Methods:a retrospective study was conducted via electronic medical records to analyze patients with tracheostomy in MICU from 1st of August, 2013 to 31st of December, 2015 (2 years and five months in total). Result: A total of 112 patients with tracheostomy were recruited with average age 71.1 years old (SD =15.2) and none of them have signed DNR agreement, with an average number of 4.3 (SD =3.6) and 3.3(SD =3.3) readmitted to hospital and ICU retrospectively during the period of study (29 months in total). There are 103 patients who have implemented tracheostomy in our hospital and all of them were with consent made by their families. Among them, 30 patients (29.1%) have received a consultation regarding tracheostomy from medical personnel in advance, but only 12 patients (11.7%) had the consultations right before surgery. The group with consultation has a significantly higher rate of discussion in their family meeting compared with the group without consultation (30% vs. 6.8%;p value = 0.002). There were 99 patients discharged from hospital with an average age 70.8 years old (SD = 15.3). Among the discharged patients, 48 patients (48.5%) were in coma or unconsciousness, 31 patients (27.7%) with pressure sores, and all of them (100%)were bedridden, dependent on others and almost all patients required 24-hour oxygen therapy and mechanical ventilation (n = 95;96%) and many of them were transferred to Respiratory care ward (RCW) (n = 42;42.4%). Conclusion: patients in MICU were mostly elder and the decision of implementing tracheostomy was made by their families. Therefore, this study suggests medical personnel should respect the medical autonomy for conscious patients. Regarding to patients who are unconscious and required full-time cares, the medical team should convene a family meeting to fully inform follow-up care of the tracheostomy, medical status and most importantly to introduce the concept that the continuation of life could not ensure patients' quality of life and to make medical decisions from the patients' point of view, providing an option to stop futile medical care.

參考文獻


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馬瑞菊、李孟君、吳珮菁、邱怡蓉、鄭婉如、李佳欣、蕭嘉瑩、蘇珉一(2019)。內科加護病房高齡病人臨終維生醫療處置之現況安寧療護雜誌23(3),205-220。https://doi.org/10.6537%2fTJHPC.201912_23(3).01
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