由加護病房重返窺看生命末期照護計畫

From ICU Return to End-of-life Care Plan

張麟(Lin Chang) ； 黃勝堅(Sheng-Jean Huang) ； 蕭勝煌(Sheng-Huang Hsiao)

《北市醫學雜誌》 12卷1期 (2015/03) Pp. 13-27

https://doi.org/10.6200/TCMJ.2015.12.1.02

摘要

目的：加護病房重返率是加護病房重要指標之一，近年來生命末期照護計畫之推動蔚為風氣，然而在統計此一重要加護病房品質指標的同時，臨床上發現有部分病人依其年齡、原始疾病或整體身體狀況，原應進入生命末期照護評估討論與規劃，卻因缺乏此方面之開放性討論與共識，而一再進出加護病房，反覆接受侵入性治療，此舉不僅造成醫療資源的大量耗費，亦使得原應安享天年的老人家或明知疾病已進展至不可逆末期的病患接受大量為延長生命卻痛苦不堪的治療方式，許多家屬在這最後一段的陪伴，亦承受身心交瘁的煎熬。方法：本研究採取回溯性研究設計（retrospective study），資料來源乃一所767床之公立區域教學醫院中心，38床內外科綜合成人加護病房病歷資料之回顧，研究對象為2011年1月至2012年11月底在某公立區域教學醫院重返加護病房之病人，總數為100位病人。統計其平均年齡，住院診斷，後續動向，不施行心肺復甦同意及是否曾經歷生命末期照護計畫。結果：本研究對象平均年齡為78.1歲，其中八十四人年齡為六十五歲以上，年紀最輕者住院時年齡為34歲，最高齡則為100歲。過去六個月內曾住院有三十七人，過去六個月內曾住入加護病房共計二十三人，其中十九位住過一次，四位住過兩次；分析病人死亡率，在後續一年內死亡高達五十人，包括四十人在本次住院中死亡；經回溯性病歷審閱及徵詢其加護病房主治醫師意見，所有病人中診斷為惡性腫瘤或健保給付八類非癌症重症末期病患共計六十四人。這些重返加護病房的病人中，可歸納出以下特點︰（一）、平均年齡高；（二）、疾病嚴重度高；（三）、住院日數長；（四）、死亡率高。而這一百位病人中，僅有十九位在轉入加護病房前曾有過末期照護的討論。結論：由本研究發現，期待當生命末期計畫討論逐步落實，家屬與醫療團隊能愈早開始朝向同一目標為病人的生命末期品質努力，便愈能減少非必要、突發的加護病房重返，如此可減少家屬心理壓力，亦能減少無效醫療造成的健康照護花費。故本研究建議要解決這樣的問題，當由政策面與教育面同時入手，使臨床工作者勇於且願意及早開啟討論的時機，民眾也能了解善終權對於生命末期品質的重要，方能為此困境解套，達到避免無效醫療及提高照護品質的雙贏局面。

關鍵字

加護病房重返 ； 生命末期照護 ； 安寧緩和 ； 無效醫療

並列摘要

Objectives: One of the most important indicators of quality of care in intensive care unit (ICU) is the return rate. For the last few years, end-of-life care has become a popular practice. Some of the patients should come to the assessment, discussion and planning of end-of-life care plan judging from their age, disease nature and overall health condition, however, due to the lack of opened discussion and consensus, they are repeatedly admitted to the ICU instead, and receive repeated invasive treatments. Not only causing massive waste of medical resources, unnecessary treatments which extend their lifespan also bring sufferings to the patients who should accomplish their days with peace and dignity, or to whom have progressed to an irreversible end stage; family members who accompany the final days are also mentally and physically tortured. Methods: This study adopted a retrospective design. Medical records of 100 patients who returned to a 38 adult surgical ICU in a 767 beds public teaching regional hospital between January 2011 and November 2012 were reviewed. Age, hospitalization diagnosis, following trends, do not resuscitate agreement and previous experience of end-of-life care of the patients were analyzed. Results: The average age of the patients was 78.1 years old, among whom 84 aged over 65. The youngest patient was 34 years while the oldest was 100 years old. Thirty seven of the patients were hospitalized and 23 admitted to the ICU over the past six months. A total of 64 patients were diagnosed with malignant tumors or the eight categories of non-cancer, national insurance payable end stage diseases. The returned patients consists the following characteristics: high average age, severe diseases, long hospitalization stay, and high mortality rate. Conclusion: This study found the earlier the initiation of discussion and implementation of end-of-life care, the sooner the patients’ families may start working together with the health care team towards the target of life quality, and reduce unnecessary and sudden return to ICU. These reduce families' psychological stress and cut down the waste of medical expenses caused by futile medical care. To solve these problems, we suggests simultaneous intervention from both health policy and educational sides, so that the clinicians may open the discussion in an earlier opportunity, the general public may appreciate the importance of hospice rights on the quality of end-oflife, and achieve a win-win scenario of avoiding futile medical care and raising quality of care.

並列關鍵字

ICU return ； end-of-life care ； palliative/hospice care ； medical futility