肝硬化臨終病人早期介入不施行心肺復甦術討論之回溯性分析

A Retrospective Study of Early Do Not Resuscitation Discussion Among Dying Patients of Liver Cirrhosis in ICU

馬瑞菊(Jui-Chu Ma) ； 李孟君(Meng-Chun Li) ； 蘇乃絹(Nai-Chuan Su) ； 吳珮菁(Pei-Ching Wu) ； 李佳欣(Chin-Hsin Li) ； 鄭婉如(Wan-Ju Cheng) ； 蕭嘉瑩(Chia-Ying Hsiao) ； 蘇珉一(Min-I Su)

《內科學誌》 30卷2期 (2019/04) Pp. 150-160

https://doi.org/10.6314/JIMT.201904_30(2).09

摘要

探討加護病房肝硬化臨終病人早期介入DNR討論之現況。採電子病歷回溯性調查設計，以加護病房2013年8月1日至2015年12月31日（共29個月）肝硬化臨終個案進行分析。病人共98位，入住加護病房24小時內有DNR討論的比率為43.9%，較未於24小時內DNR討論之病人其在APACHE II分數（31.1±7.9vs.25.3±9，p＝0.001）顯著為高，但在加護病房住院天數（3.2±3.6vs.9.4±11，p＜0.001）、呼吸器使用天數（2.4±2.5 vs. 7.8±10.6，p＝0.001）、醫療支出（91709.4±82505.2 vs. 238628.1±237061.9，p＜0.001）等顯著減少，而早期介入DNR討論之病人其在臨終前24小時大多數仍接受維生醫療包含；血管升壓藥物60.5%、侵入性血壓生命跡象監視治療72.1%、輸血治療53.5%、點滴輸液治療97.7%、呼吸器76.7%、氣管內管或氣切81.4%、抗生素治療93%、中心靜脈導管88.4%、抽血檢查79.1%、放射線檢查67.4%、鼻胃管95.3%、導尿管93%等。早期介入DNR討論與肝硬化臨終病人加護病房住院天數、呼吸器使用天數、醫療支出等具有統計之顯著差異，然超過一半以上之病人臨終前24小時仍持續維生醫療。因此建議對於肝硬化末期病人除儘早介入DNR討論外仍應實施有效之醫病共享決策，在尊重病人偏好及價值觀之下討論停止無效維生醫療，避免病人受苦。

關鍵字

加護病房（Intensive care unit） ； 肝硬化（Liver cirrhosis） ； 臨終病人（Dying patients） ； 不施行心肺復甦術討論（Do Not Resuscitate discussion） ； 維生醫療（Life sustaining treatments）

並列摘要

This study aims to explore the current status of early Do Not Resuscitate (DNR) discussion in dying patients of liver cirrhosis in the intensive care unit (ICU). This study is retrospective analysis of dying patients with cirrhosis in ICU from August 1, 2013, to December 31, 2015 (a total of 29 months).Total 98 dying cirrhotic patients were enrolled in this study, 43.9% patients have discussed DNR within 24 hours after ICU admission, and their APACHE II score (31.1±7.9 vs. 25.3±9, p=0.001) is significantly higher than those who do not discuss DNR within 24 hours after ICU admission. However, the DNR-discussed within 24 hours patients' hospitalization days (3.2±3.6 vs. 9.4±11, p＜0.001), days of mechanical ventilation (2.4±2.5 vs. 7.8±10.6, p=0.001), and medical expenditure (91709.4±82505.2 vs. 238628.1±237061.9, p＜0.001) are significantly lower than patients without DNR discussion within 24 hours. Most of patients with early DNR discussion still receive life sustaining treatments (LST) within the last 24 hours before death, such as vasopressor (60.5%), invasive blood pressure & vital signs monitoring (72.1%), blood transfusion (53.5%), intravenous therapy (97.7%), mechanical ventilation (76.7%), endotracheal tube or tracheostomy tube (81.4%), antibiotic treatment (93%), central venous catheter (88.4%), blood test (79.1%), radiographic testing (67.4%), NG tube (95.3%), and urinary catheter (93%). The early discussion of DNR is significantly associated with number of hospitalization days, days of using mechanical ventilation, and medical expenditure of dying patients with cirrhosis, but over half of the patients still receive LST within the last 24 hours before death. To reduce patient suffering, we need to discuss about when to stop ineffective LST depending on patients' preferences and values. Therefore, dying patients with cirrhosis should not only have an early discussion of DNR but also receive shared decision making about LST effectively.