不同疾病分類在內科加護病房末期病人之緩和醫療決策分析

Analysis on Palliative Medical Decision for ICU Patients at Terminal Stage with Different Disease Categories

馬瑞菊(Jui-Chu Ma) ； 李孟君(Meng-Chun Li) ； 邱怡蓉(Yi-Jung Chiu) ； 鄭婉如(Wan-Ju Cheng) ； 李佳欣(Chin-Hsin Li) ； 蕭嘉瑩(Chia-Ying Hsiao) ； 蘇珉一(Min-I Su)

《內科學誌》 30卷3期 (2019/06) Pp. 213-221

https://doi.org/10.6314/JIMT.201906_30(3).06

摘要

探討不同末期疾病分類病人之緩和醫療決策。採電子病歷回溯性調查設計，以2013年8月1日至2015年07月31日入住內科加護病房病人1103人中符合Salpeter（2012）末期定義（存活期＜＝6M）之584人為研究對象。末期病人平均年齡以肝衰竭55歲（SD＝13.7）為低、不施行心肺復甦術（Do Not Resuscitate，DNR）討論以心衰竭為低（佔16.3%），死亡率以肝衰竭為高（佔55.8%）。不同疾病分類之末期病人其在性別、年齡、DNR簽署、住院中死亡、疾病嚴重程度APACHE II score、呼吸器使用天數、加護病房住院天數等有顯著差異（P＜0.05），而在住院期間是否有裝置中心靜脈導管、心肺復甦術（Cardiopulmonary Resuscitation，CPR）、洗腎、使用呼吸器等醫療處置亦有顯著差異。所有符合末期定義病人中又以老年症候群最多（佔53%），且老年症候群的共病比率最高，其次依序為心衰竭、腎衰竭、慢性阻塞性肺病（Chronic Obstructive Pulmonary Disease，COPD），而以肝衰竭之共病最少。統計死亡病人其DNR討論距離死亡的平均時間為3.8～10.4天。不同末期疾病病情表現差異極大且DNR討論時間較遲，因此對於疾病之臨床進程應有不同的DNR討論及緩和醫療介入時機，而內科加護病房末期病人以老年症候群及共病較多，除需重視高齡病人在加護病房的善終外，未來須協助病人了解不同疾病臨床進程及治療選擇的意義。

關鍵字

加護病房（Intensive care unit） ； 疾病分類（Disease Categories） ； 末期病人（Terminal stage） ； 不施行心肺復甦術討論（DNR discussion） ； 緩和醫療決策（Palliative medical decision）

並列摘要

To explore the medical decision for patients with different disease categories. Retrospective study on electronic medical record. Study subjects are targeted at 1103 patients who live in intensive care units from 1st August 2013 to 31st July 2015 and whose conditions match the definition of a terminal stage (＜= 6 month survival) by Salpeter (2012).The youngest average age of patients at terminal stage is 55 years old with hepatic failure (SD =13.7). Do Not Resuscitate (DNR) discussion has seen the lowest proportion with heart failure (16.3%), while the death rate in hepatic failure accounts for the highest (55.8%). For patients at terminal stage with different disease categories, remarkable differences (P＜ 0.05) are shown in gender, age, DNR execution, dying during hospitalization, the level of severity reaching APACHE II score, the number of days using ventilators, and the number of days staying in ICU. What is more, considerable differences can also be identified in whether medical treatment, such as central venous catheter, Cardiopulmonary Resuscitation (CPR), kidney dialysis or ventilators are applied. Another finding is that geriatric syndrome appears to make up the largest proportion (53%) of all patients who match the definition of a terminal stage, and the ratio of geriatric syndrome's comorbidity is the highest. The next is followed by hear failure, hepatic failure, Chronic Obstructive Pulmonary Disease (COPD), while the comorbidity of hepatic failure happens the least. Furthermore, the survey concludes that the average number of days prior to death after DNR discussion has been done is 3.8 to 10.4 days. There is a huge discrepancy in the conditions of different terminal disease. Moreover, as DNR discussion is done at a later stage, distinct DNR discussions and the intervention time of palliative care should be adopted for the clinical progress of a disease. Geriatric syndromes and comorbidity happens more on the patients at terminal stage in ICU. To be considered in the future to assist patients to understand the clinical progress on different diseases and the meaning of each treatment choice.