內科加護病房急慢性透析病人簽署DNR同意書與醫療處置之經驗分析

The Empirical Analysis of DNR Order on Medical Treatment for ICU Acute and Chronic Dialysis Patients

林淑茹(Su-Ju Lin) ； 馬瑞菊(Jui-Chu Ma) ； 黃琬庭(Wan Ting Huang) ； 梁婉真(Wan Ting Lian) ； 林佩璇(Pei Xuan Lin) ； 鄭婉如(Wan J Cheng) ； 蕭嘉瑩(Jia Yin Hsiao) ； 郭豐吉(Ji Feng Guo) ； 蘇珉一(Min-I Su)

《安寧療護雜誌》 23卷2期 (2019/06) Pp. 113-128

https://doi.org/10.6537/TJHPC.201906_23(2).01

摘要

研究目的：探討內科加護病房透析病人安寧療護之經驗。材料與方法：採電子病歷回溯性調查設計，以內科加護病房2013年8月1日至2015年7月31日（共2年）透析病人進行描述性統計分析。結果：透析病人共145位，平均年齡為65.81歲（SD=14.50），男性為55.2%，常規透析者為49.7%，緊急透析者為50.3%，整體拒絕心肺復甦術（Do Not Resuscitate；DNR）簽署的比率為42.8%，住院前預立醫療指示（Advance directive；AD）為0%，整體住院死亡率為37.2%，臨終前24小時仍接受透析醫療處置為53.7%，死亡前有接受CPR者為11.1%。僅有10人決定不予透析（Do not dialysis；DND），其中死亡者6位，統計從DND距離死亡的平均時間約3天（67.1小時）。討論：內科加護病房透析病人死亡率高，但簽署DNR及安寧意願書比率僅約五成。因此建議在加護病房之透析病人處於生命末期階段或對醫療處置反應效果差的透析病人，若能儘早與家屬充分溝通減少或不予透析之必要性，而是給予緩和舒適的照護，減少無效醫療，就能減少生命末期不必要的治療，讓家屬在有限的時間裡全程陪伴病人並做最後的告別，維持最終的尊嚴。

關鍵字

加護病房 ； 透析病人 ； 不予透析 ； 不施行心肺復甦術 ； 緩和醫療

並列摘要

Purpose: The purpose of this study is to explore the experience of DNR orders on medical treatments for ICU dialysis patients. Methods: The retrospective study from electronic medical records is collected to analyze the dialysis patients in the medical ICU from August 1st 2013 to July 31st 2016 (total 2 years). Results: Total 145 dialysis patients were recruited, the average age was 65.81 (SD=14.50), 55% of the study cases were male, and 45% were female. The regular dialysis and emergent dialysis were 49.7% and 50.3%, respectively. The patients with DNR (Do Not Resuscitate) order were 42.8%, no one has AD (Advance directive). The intra-hospital mortality is 37.2%. The patients still received dialysis within the last 24 hours before Death were 53.7%. The patients were performed CPR (Cardiopulmonary Resuscitation) before death were 11.1%. Total 10 patients choose DND (do not dialysis), 5 patients had intra-hospital mortality. The average time from DND to death was 67.1 hours (SD=89.7). Conclusion: High mortality rate of dialysis patients in medical ICU, But in this study, the rate of the patients with DNR order and ADonly about 50%. Therefore, it is recommended that patients who have a poor response to medical treatment at the end of their lives should be considered as soon as possible to reduce or do not dialysis, to do palliative care and comfortable nursing and not to do medical futility. The dialysis patients in ICU are provided with the information of palliative care as early as possible and discuss the necessity of continuous dialysis with family. For the DND patients, we could not only promptly provide the palliative care policy but also let the family members accompany the patient and make the last farewell within the limited time.

並列關鍵字

ICU: Intensive Care Unit ； dialysis patients ； do not dialysis ； DNR: Do-Not-Resuscitate ； Unhelpful treatment

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