某區域醫院內科加護病房高齡末期病人DNR討論之現況

Current Status of DNR Discussion Concerning Terminally Ill Elderly Patients in the ICU of a Regional Hospital

馬瑞菊(Jui-Chu Ma) ； 李孟君(Meng-Chun Li) ； 邱怡蓉(Yi-Jung Chiu) ； 黃美娟(Mei-Juan Huang) ； 涂穎慧(Ying-Huei Tu) ； 李佳欣(Chia-Hsin Li) ； 林佩璇(Pei-Xuan Lin) ； 鄭婉如(Wan-Ju Cheng) ； 蕭嘉瑩(Chia-Ying Hsiao) ； 吳珮菁(Pei-Ching Wu) ； 潘宥妤(Yu-Yu Pan) ； 蘇珉一(Min-I Su)

《台灣老年醫學暨老年學會雜誌》 13卷3期 (2018/08) Pp. 153-168

https://doi.org/10.29461/TGGa.201808_13(3).0002

摘要

研究目的：探討內科加護病房高齡末期病人不施行心肺復甦術(DNR)討論之現況。材料與方法：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之高齡病人為研究對象。結果：入住加護病房高齡病人（≥65歲）佔55.9% (617/1104)，預立安寧緩和意願書比率為0.65%、撤除維生醫療比率為1.8%，而高齡病人符合Salpeter (2012)末期定義（存活期≤6M）者共395位（佔64%），其中24小時內介入DNR討論為28%，早期介入DNR討論之個案其在年齡、疾病嚴重程度(APACHE II)皆較無介入DNR討論者顯著為高，但在加護病房住院天數及GCS分數顯著為低。結論：入住加護病房之高齡病人近六成，卻有一半以上為末期病人，但高齡末期病人預立安寧緩和意願及撤除無效維生醫療比率極低且早期介入DNR討論比率不到三成，惟早期介入DNR討論可以顯著減少加護病房住院天數，因此建議除宣導高齡民眾醫療自主決策外對於入住加護病房高齡末期病人須儘早介入DNR討論並提供緩和醫療之選項，撤除無效延命醫療避免高齡病人受苦。

關鍵字

加護病房 ； 高齡末期病人 ； 不施行心肺復甦術 ； 不施行心肺復甦術討論 ； 緩和醫療

並列摘要

Objectives: This study aimed at examining the current status of DNR (do not resuscitate) discussion concerning the terminally ill elderly patients in the intensive care unit at a regional hospital. Methods: Based on an electronic medical record backtracking survey design, the study analyzed the individual cases of terminally ill elderly ICU patients during the two-year period from August 1, 2013 to July 31, 2015. Results: Elderly patients accounted for 55.9% of the total number of ICU patients (617/1104). Only 0.65% and 1.8% of the elderly ICU patients gave written instruction respectively for receiving hospice palliative care and for withdrawing life-sustaining treatments. 64% of them (396/617) met the definition of terminal stage (survival stage ≤6M) proposed by Salpeter (2012), and 28% of the terminally ill elderly ICU patients were engaged in DNR discussion within 24 hours. The age and APACHE II of the patients entering early DNR discussion were significantly higher than those entering no DNR discussion, yet the length of ICU stay and GCS score of the former group were significantly lower than those of the later group. Conclusion: Elderly patients accounted for 55.9% of the ICU residents, and over half of them were terminally ill patients. However, the percentages of the terminally ill elderly ICU patients pre-establishing agreement for receiving hospice palliative care and withdrawing ineffective life-sustaining treatments appeared to be extremely low, and less than 30% of them entered early DNR discussion. Early DNR discussion has been found to significantly decrease the length of ICU for elderly patients. Therefore, it is suggested that, in addition to promoting independent decision making among elderly patients, hospitals should encourage terminally ill elderly ICU patients to participate in early DNR discussion and inform them of the option of hospice palliative care so as to free them from prolonged suffering by agreeing to the withdrawal of ineffective life-sustaining treatments.

並列關鍵字

intensive care unit ； elderly patients with end-stage ； do not resuscitate ； DNR discussion ； palliative care