末期透析病人死亡前使用安寧緩和醫療與否之生命末期照護品質與照護費用影響

研究背景與目的：末期透析病人是近年來接受安寧緩和醫療的末期非癌症病患中，數量成長最快速的。當生命走到近終點時，是否要持續維持生命治療—如血液透析—，或是面對未來可能須接受更侵入性維持生命治療—如插管、呼吸器等—之抉擇，常常是病人和家屬難以抉擇的問題，除了病人和家屬的壓力之外，也造成了照顧和社會成本的增加。本研究主要的目的是探討末期透析病人是否有接受安寧緩和醫療與生命末期照護品質的相關性，期待透過全國性的回溯性資料分析，釐清安寧緩和醫療對於末期透析病人的效益，包含生命末期積極照護利用與醫療費用，並進一步分析何種安寧緩和醫療模式對於末期透析病人的效益較高。研究方法：本研究以回溯性世代研究分析，運用台灣健保資料庫中2017年全國的末期透析病人，了解死亡前一年的安寧照護利用率、安寧照護針對透析病人生命末期照護品質的效益、以及不同安寧照護模式帶來的影響，同時分析影響末期透析病人生命末期照護品質的決定因子。研究結果：共有10,083位末期透析病人被納入研究中，其中有1,786位病人(17.7%)在死亡前一年有接受安寧緩和療護，而8,297位病人(82.3%)死亡前沒有接受安寧緩和療護。所有病人的平均死亡年齡為73.6歲。末期透析病人在死亡前接受安寧照護可顯著降低死前30天超過一次急診(勝算比0.68)、死前30天超過一次住院(勝算比0.62)、死前30天使用急性加護病房(勝算比0.70)、在醫院死亡(勝算比0.93)、死前30天使用插管(勝算比0.38)、死前30天使用呼吸器(勝算比0.83)、死前30天使用心肺復甦術(勝算比0.23)、死前30天使用鼻胃管、胃造口或全靜脈營養(勝算比0.91)以及二項積極照護分數比率。而在生命末期醫療費用方面，是否有接受安寧緩和照護並不會顯著降低死亡前30天醫療費用。結論：這個全國性的觀察性研究分析了超過一萬名末期透析死亡病人的生命末期照護品質，結果顯示安寧緩和醫療，特別是混和安寧緩和醫療模式、安寧住院照護與安寧居家照護，都可以顯著降低病人死亡前的積極治療措施。而安寧共同照護相對來說對於降低積極性治療的效果較差。衛生主管機關與政策制定者應該設法將安寧緩和醫療融入末期透析病人的臨床照護模式當中，並且試圖促進腎臟照護團隊與安寧照護團隊的對話、溝通和合作，以提升末期腎病病人與家屬的生活品質。

關鍵字

安寧緩和醫療；末期腎臟病；透析治療；生命末期照護品質

並列摘要

Background: Patients with end-stage renal disease (ESRD) under regular dialysis are a particularly important population with a heavy disease burden. However, evidence related to palliative care for patients with ESRD under regular dialysis remains scarce, especially for palliative care consultation services and palliative home care. This population-based observational study aimed to evaluate the effects of different palliative care models on aggressive treatment and medical costs during the end of life (EOL) among ESRD patients under regular dialysis. Methods: This population-based study used a population database maintained by Taiwan’s Ministry of Health and Welfare in combination with Taiwan’s National Health Research Insurance Database. We enrolled all decedents who were ESRD patients under regular dialysis from Jan 01, 2017 to Dec 31, 2017 in Taiwan. Hospice care during the one year before death was documented, and we analyzed the relationship between different palliative care models and treatment aggressiveness during EOL by multivariate logistic regression. Also, we examined the relationship between different palliative care models and medical costs within 30 days before death. Results: A total of 10,083 patients were enrolled, and 1,786 (17.7%) ESRD patients received palliative care within one year before death. Compared with patients with no palliative care, patients with palliative care during the EOL had significantly less aggressive treatment during the EOL (Estimates: -0.09, Confidence interval: -0.10- -0.08). Patients with inpatient palliative care, palliative home care, and mixed model had significantly lower treatment aggressiveness during the EOL. Whether to receive palliative care or not before death did not significantly decrease medical costs within 30 days before death. Conclusions: Palliative care, especially the mixed care model, inpatient palliative care, and palliative home care in ESRD patients under dialysis during the EOL, could significantly reduce the aggressiveness of treatment during the EOL.

並列關鍵字

Hospice-palliative care ； End stage renal disease ； Dialysis ； Quality of life ； End-of-life

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