安寧緩和醫療修法後對巴拉刈中毒末期病人醫療過程之影響

Influence to Paraguat Intoxication Terminal Patient Care after Hospice Palliative Care Regulation Revision

馬瑞菊(Jui-Chu Ma) ； 鄭婉如(Wan-Ju Cheng) ； 林佩璇(Pei-Xuan Lin) ； 李佳欣(Chin-Hsin Li) ； 涂穎慧(Tu-Yin Hui) ； 蘇珉一(Min-I Su)

《安寧療護雜誌》 21卷1期 (2016/03) Pp. 46-60

https://doi.org/10.6537/TJHPC.2016.21(1).4

摘要

研究目的：探討2013年安寧緩和醫療修法前、後加護病房巴拉刈中毒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，以加護病房2009年1月至2015年12月中毒之個案進行分析，並以自擬結構性調查表進行資料收集及統計。結果：收案之68位個案基本資料並無統計上之差異。50位死亡個案中在安寧修法後之病人全數皆簽署DNR(n=22;佔100%)，且有19位(佔86%)死亡前未使用強心藥物，選擇不予處置(Withholding of Life Sustaining Treatment)(插管併呼吸器)的有16位(佔72.73%)。有9人(佔41%)使用緩和鎮靜藥物(Morphine)，加護病房平均住院日由修法前的4.14天(SD=4.49)下降為修法後之2.18天(SD=1.47)，以上皆達統計上顯著差異。住院期間之醫療支出，由修法前的93811.93 台幣降至修法後之63164.82 台幣(下降23%，近30000元之支出)。結論：嚴重巴拉刈中毒病人病情進展快速，短期內即進展到死亡，若能及時提供末期巴拉刈中毒病人(或家屬)緩和醫療之治療方針及維生醫療抉擇之討論，不僅可以避免無效之延命醫療，使病人能安祥有尊嚴的離世，亦可讓家屬在有限的時間裡陪伴病人並做最後的告別。

關鍵字

巴拉刈中毒 ； 不予處置維生醫療 ； 緩和醫療 ； 緩和鎮靜 ； 醫療支出

並列摘要

Objectives: To discuss the experience of hospice care to paraguat intoxication patient in intensive care unit before and after Taiwan hospice palliative care regulation revision in 2013. Method: Adopt the electronic medical record backtracking survey design, analyze the individual case of intoxication in intensive care unit from January of 2009 to December of 2015, and collect and make statistics of data through the self-prepared structural questionnaire. Result: There is no significant difference in basic characteristics among the collected 68 cases. In the 50 death cases, all the patients have accepted DNR(n=22;100%) after the hospice regulation revision, and 19 cases (86%) did not use the inotropic agent before died, and 16 cases (72.73%) selected the withholding of life sustaining treatment(such as intubation with ventilator) for life sustaining treatment. 9 cases (41%) used the palliative sedation (Morphine) medicine. The average length of stay in intensive care unit decreases from 4.14 days before the regulation revision to 2.18 days after the regulation revision, and the data above all realize the statistical significant difference. The medical expenses during the hospital stay decreases from NT$ 93,811.93 before the regulation revision to NT$ 63,164.82 after the regulation revision (decreased 23%, nearly NT$ 30,000). Conclusion: The state of severe paraguat intoxication patient develops rapidly, to the death in the short term. If it could timely provide the palliative care treatment policy and selection discussion of Life Sustaining Treatment to the paraguat intoxication terminal patient and family members, it could not only avoid the futile life extension treatment, to allow the patient passing away in peace and with dignity, but also let the family members accompany the patient and make the last farewell within the limited time.

並列關鍵字

Paraguat intoxication ； Withholding of Life Sustaining Treatment ； palliative care ； palliative sedation ； medical expenses

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