緩和醫療家庭會議之內容與不施行心肺復甦術決定之關聯性

The association between the content of palliative family conferences and do-not-resuscitate decisions

張炳勛(Ping-Hsun Chang)

指導教授 ： 陳彥元

國立臺灣大學/醫學院/醫學教育暨生醫倫理研究所/碩士(2016年)

https://doi.org/10.6342/NTU201602863

摘要

民國101年12月起，為鼓勵安寧緩和醫療及末期病人預立醫囑，台灣之全民健康保險增列「緩和醫療家庭諮詢費」。透過此一給付，家庭會議開始有正式之記錄。在末期或重症醫療情境中，醫病溝通時常不足。家庭會議做為溝通之重要手段雖已有共識，但在台灣，有關家庭會議之實證研究仍相當有限。
本研究為一回溯性觀察研究，收集台大醫院腫瘤科病房2014年12月至2015年11月申報緩和醫療家庭諮詢費之病患共248人，分析患者之人口學變項、疾病嚴重度、參與家庭會議之角色及人數、家庭會議內容，以及相關醫療處置等，以迴歸分析家庭會議中可能影響「不施行心肺復甦術」之決定的因子。
研究發現，在家庭會議後一週、二週、一個月及追蹤結束(2016/5/31)時，會顯著提高不施行心肺復甦術之決定的因子有：照會安寧緩和醫療團隊、會議時之ECOG分數較高、病情緩慢惡化中或病危、癌症有遠端轉移、淋巴球百分比較低、醫療團隊出席會議人數較多，和信仰佛、道教或民間信仰。而其中最重要且效果持久的因素是照會安寧緩和醫療團隊，其次則是會議時之ECOG。而年齡、性別、該次住院是否使用抗癌藥物、患者本人是否出席、會議中是否討論DNR相關議題等，與患者在上述四個時間點是否決定DNR沒有顯著的關聯性。會議前仍在使用抗生素、未婚離婚分居或喪偶等婚姻狀態，在家庭會議後的兩天內與DNR之決定有關。家庭會議中有若男性家屬出席可能也對DNR決定的速度有影響。患者本人的出席與否，則與性別、年齡、ECOG、參與會議的人數、男性親友出席會議，和會議中是討論DNR相關議題有關。

關鍵字

家庭會議 ； 不施行心肺復甦術 ； 自主決定 ； 末期疾病 ； 緩和醫療 ； 腫瘤 ； 癌症

並列摘要

Since Dec 2012, Taiwan's National Health Insurance started to cover palliative family conference, and formal meeting records were required for the payment package.
In critical or terminal diseases, the communication between patients, their families and medical teams are often insufficient. Family meetings serve an important role in medical communication. But only few empirical studies exist for the famliy meetings in Taiwan.
This is a retrospective cohort study. All family meeting payment package records in a medical center in northen Taiwan were collected from Dec 2014 to Nov 2015. 248 patients and their medical records, including variables of demographic data, diseae severity, participants and the content of the family meetings, and relevant medical interventions, were included. Multivariate logistic regression was performed to identify the association of these factors and the designation of Do-Not-Resuscitate (DNR) decisions.
The association was tested in 7 days, 14 days, 30 days after the family meeting, and on May 31, 2015. The result showed that consulting a palliative team, high ECOG score during the meeting, disease in progression or imminent dying, distant metastasis, low lymphocyte percentage, more medical personnel attending the meeting, and believing in Buddism, Daoism or Taiwanese Folk Religion, were signinificantly and positively assosicated with DNR dicisions. Age, gender, using anti-cancer medication, the patient's participation of the family meeting, and discussing about DNR during the meeting, showed no significant association. Taking antiiotics during the meeting and marital status were significant only within 2 days after a family meeting. Having male family members in the meeting also potentially influences the DNR decisions.
We also analysed factors influencing a patient's participation of a family meeting. The significantly associated variables were: age, gender, ECOG, number of participants, having male family members in the meeting, and discussing about DNR in the meeting.

並列關鍵字

family conference ； do-not-resuscitate ； DNR ； autonomy ； terminal illness ； palliative care ； cancer

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