社區醫療照護模式中末期患者家屬參與患者之「預立醫療計劃討論」的心理歷程特徵

Psychological Process of Family Members Participating in Terminal Patients’ Advance Care Planning in Home-based Care Model

何雪綾(Hsueh-Lin Ho)

指導教授 ： 吳英璋 ； 林耀盛

國立臺灣大學/理學院/心理學研究所/博士(2015年)

https://doi.org/10.6342/NTU.2015.00199

摘要

目的：由心理歷程角度探討預立醫療計劃的研究經常欠缺明確的理論對應；且偏重預立醫囑簽署與意願調查，對「討論行為」的心理歷程關注相對不足。此外，國內末期醫療決策文件多由病患家屬代理簽署，但以家屬為對象的研究為數仍少。本研究以健康行為理論為視角，探討社區醫療末期患者之家屬參與患者的「預立醫療計劃」的心理歷程特徵。研究問題為：家屬參與患者之預立醫療計劃，其討論行為於不同行為改變階段有何具體表現以及心理歷程特徵。方法：個案研究法；參與者為十位社區醫療居家照護末期病患之家屬；資料收集包含（1）預立醫療計劃討論錄影以及（2）預立醫療計劃討論經驗的個別訪談；兩者分別以互動歷程分析以及主題分析法分析。結果：歸納呈現家屬參與病患之預立醫療計劃的討論行為，在「個人反思與主張表達」、「與病人的溝通」、「與親友的溝通」、「與醫療團隊的溝通」等面向於各行為改變階段的具體表現及行為預期內涵。討論與結論：（1）以改變階段觀點結構「討論行為」除了可具體化行為內涵，亦凸顯行為的複雜性；（2）「結果預期」概念中的「重要性評估」有助於探討「被動的討論行為反應」；（3）「『疾病 vs. 病痛』的生病經驗角度」、「醫病關係」、「關係取向文化脈絡」是未來預立醫療計劃研究值得探討的議題。

關鍵字

預立醫療計劃 ； 跨理論模式 ； 社會認知理論 ； 預期 ； 社區醫療

並列摘要

Purpose: Past studies of advance care planning (ACP) mostly focused on the inclination and completion rate of advance directives and failed to make a rationale of study connected to health behavior-related theories. In Taiwan, while terminal patients’ advance directives were largely subscribed to family members, studies investigating family members’ experiences were relatively sparse. This study adopted the transtheoretical model (TTM) and social cognitive theory as frameworks and investigated characteristics of the psychological process (including stages of change and behavior expectancy) of terminal patients’ family members participating in patients’ ACP in a home-based caring setting. Method: This study used case-study methods. Ten family members of terminal patients were recruited. The data collected mainly included (1) a video of the course of communicating ACP between family members and medical staff and (2) one-on-one, semi-structured interviews with family members. The above data were analyzed with interaction process analysis and thematic analysis, respectively. Result: Family members’ behavior in discussions unfolded in four aspects, including “reflection and expression of personal viewpoint,” “communication with patient,” “communication with relatives,” and “communication with medical staff.” Concrete behaviors in the above four aspects were classified to depict each stage of change in participating in discussions of ACP, and related experiences that might reflect discussion behavior were also presented. Discussion & Conclusions: (1) The “stage of change” of TTM helped not only to depict behavior in discussing ACP in concrete terms, but also to reveal the complexity of discussion behavior; (2) “passive behavior” in discussion can be characterized by its evaluation result of low importance in outcome expectancy; and (3) “disease-versus-illness” explanatory models of sickness, the “physician-patient relationship,” and the “indigenous relationship-oriented cultural context” are important issues to be considered in future study of ACP.

並列關鍵字

advance care planning ； transtheoretical model ； social cognitive theory ； expectancy ； community medicine

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