末期頭頸癌病患接受臨終積極治療的社會經濟因素

Socioeconomic Determinants of aggressive end-of-life care for terminal patients of head and neck cancer

黃郁絜(Yu-Chieh Huang)

指導教授 ： 陳端容

國立臺灣大學/公共衛生學院/公共衛生碩士學位學程/碩士(2022年)

https://doi.org/10.6342/NTU202200293

摘要

研究背景: 2020年度台灣衛生福利部的統計，口腔癌為第六大癌症死因，相較於同年度世界衛生組織的統計，口腔癌並不屬於前十大癌症死亡名單，這表示台灣口腔癌族群明顯與世界趨勢不同。許多研究提出低社會經濟地位的病患，在癌症生命末期死亡前三十天，偏向堅持可能痛苦而且醫學原理上無效的治療。過度積極的治療包含1.接受化學治療，2. 曾經到過急診求助3. 住院超過一次 4. 住院超過十四天 5. 加護病房收治 6. 死亡於急性醫院。
研究目的與方法：本研究針對基隆長庚醫院，頭頸癌病患於2016/01/01至2018/12/31於基隆長庚醫院與情人湖院區死亡，死前三十天的病歷記錄統計，驗證低社會經濟地位（包含性別、工作、婚姻狀態、教育程度）與堅持過度醫療是否有正相關。
研究結果：總共103位頭頸癌病患納入研究統計，其中7位無關頭頸癌本身因素死亡而排除，最終符合者為96位，平均死亡年齡為60歲，89位為男性、國小以下學歷40位、國中23位、高中職23位而大學學歷只有10位。有工作35人、已退休22人、沒有工作39人。未婚15人、已婚60人、離婚17人、喪偶4人。
死前三十天內，接受化學治療34 (35.4%) 位，曾經到過急診求助47 (49%) 位，住院超過一次13 (13.5%) 位，住院超過十四天68位（70.8％），加護病房收治28 (29.2%) 位，死亡於急性醫院96 （100%）位。六項分別給予過度醫療一分，去癌末臨終前接受過度醫療的程度判定，總分零到六分。最後發現平均每位病患有3.69分。
研究結論：96名病患平均接受3.69項過度醫療，經過ＳＰＳＳ軟體計算，發現無論是性別、工作、婚姻狀態、教育程度都不會與死前三十天過度醫療有顯著相關(p>0.05)。值得一提的是，喪偶者可能比其他婚姻狀態者選擇更少的死前三十天過度醫療 (B=-0.882, SE=0.470, p=0.064)，因為先前的文獻從未提及喪偶與否在婚姻狀態的重要性，此一發現值得近一步的探討與研究。
雖然在組間的比較沒有顯著差異，但是整體平均分數(平均3.69，標準差0.86)相較先前台灣的全癌種 (平均1.46，標準差1.26) 或是口腔癌 (平均2.68，標準差1.37)，各項過度臨終醫療的佔比，也都比之前的文獻高：化學治療10.1%~14.1%，住院超過一次或超過14天55.3%~59.3%，加護病房收治15.9%~20.6%。
此研究結果顯示，頭頸癌末期病患，不管社會經濟地位如何，整體接受過度生命末期醫療的比例就是比較高。也許只有喪偶者比較傾向不要太積極。

關鍵字

癌末過度醫療 ； 社會經濟地位

並列摘要

Background: According to the Ministry of Health and Welfare Taiwan, oral cancer ranked the top 6th cause of cancer death while it is not within the top ten cancer death list by World Health Organization (WHO) in 2020. This phenomenon signifies the unique presence of this cancer population in Taiwan. Previous studies suggested terminal cancer patients with low socioeconomic status (SES) received more aggressive end-of-life (EOL) care, including chemotherapy, emergency room (ER) visits, intensive care unit (ICU) admission, and death in an acute-care hospital.
Methods：This study uses a single-center database from the cancer center in Kee Lung Chang Gung hospital (KL CGMH) for those terminal patients with head and neck cancer who died in KL CGMH between 2016/01/01 to 2018/12/31 identified. Their socioeconomic status, including gender, occupation, marital status and education levels, and aggressive EOL care, were obtained from electronic medical records in KL CGMH.
Results: 103 head and neck cancer (HNC) patients selected and a total of 96 patients met the criteria of inclusion (7 died from irrelevant cause to head and neck cancer). The average age of death in 60, 89 patients were male. Education levels 40 below 6th grade, 23 high school graduates, 23 senior high school graduates, and 10 graduate from college or above. Thirty-five had a job, 22 were retirees, and 39 were unemployed. Marital status as 15 single, 60 married, 17 divorced, and 4 widowed.
During the last 30 days of these, 34 (35.4%) patients received chemotherapy, 47 (49%) patients had visited ER, 13 (13.5%) patients were admitted to hospital more than once, 68 (70.8%) patients had stayed in our hospital more than 14 days, 28 (29.2) patients eventually admitted to ICU all of 96 (100%) were announced expired in KL CGMH. The 6 managements were given 1 score for each management. The result shown mean score for these 96 patients is 3.69. There is no significance within the SES variables between patients in this study, but much higher than other studies including cancers of all sites as well as cancers of specific sites.
Conclusion: In average, these patients received 3.69 scores. Statistic calculation using Statistical Product and Service Solutions (SPSS) and neither of gender, occupation, marital status, and education levels correlate to the decision of aggressive EOL care (p>0.05). Interestingly it is worth mentioning is that widowers tended to receive less aggressive EOL relatively (B=-0.882, SE=0.470, p=0.064). Widowers/widows has not been a specific issue or category when mentioning about marital status. People who have lost their spouses may be a specific category for studies in the future.
Despite of insignificant result of 4 SES factors towards taking more aggressive EOL care within terminal HNC patients in this study, the mean scores and the percentage of each aggressive EOL taken are all much higher than prior studies. The mean scores are 3.69 (SD 0.86) while prior studies showed mean = 1.46 (SD 1.26) with cancers of all sites and mean = 2.68 (SD 1.37) for oral cancer. Prior study by Aaron D. analyzing patients who died between 2007 and 2014 with metastatic lung, colorectal, breast, pancreatic and prostate cancers. In the last 30 days of life, 10.1% to 14.1% of patients received CT, 15.9% to 20.6% of patients admitted to ICU, more than half (55.3%–59.3%) were admitted to the hospital and about one-third (30.3%–35.4%) died in the hospital. These data are far less than data in our study.
The result of our study has shown terminal HNC cancer patients strive for aggressive EOL care regardless of their SES, but possibly except for widowers.

並列關鍵字

Aggressive terminal end-of-life care ； socioeconomic status

參考文獻

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