探討臨床醫師對預立醫療照護諮商之態度(質性研究)

Attitude of the Physicians toward Advance Care Planning: A Qualitative Study

施銘峰(Ming-Feng Shih)

指導教授 ： 朱宗信

共同指導教授 ： 楊志偉(Chih-Wei Yang)

國立臺灣大學/醫學院/醫學教育暨生醫倫理研究所/碩士(2020年)

https://doi.org/10.6342/NTU202001834

摘要

背景：預立醫療照護諮商(advance care planning, ACP)提供意願人對特定醫療決定選擇的機會，當意願人無決定能力時，之前所立下的預立醫療決定(advance directive, AD)，在臨床決策中就成了病人意願的延伸，是病人自主的表現。我國於2015年12月18日由立法院三讀通過病人自主權利法，並已於2019年1月6日實施，賦予預立醫療決定正式的法律效力。醫師對預立醫療照護諮商的態度會影響他與病人間開啟相關討論的可能性，本研究欲探討臨床醫師對於參與ACP的態度以及相關的影響因素。
方法：本研究是質性研究，受訪對象透過效標取樣(criterion sampling)，選取臨床業務與病人自主權利法最相關的專科醫師，如腫瘤科、神經科、精神科、家醫科等來接受訪問。訪談過程採用半結構式(semi-structured)的深度訪談法(in-depth interview)。訪談過程全程錄音，並製作逐字稿，繼而採用編輯式(editing method)來進行分析，形成意義單元、次主題及主題。
結果：本研究針對16名醫師進行了深度訪談後達到理論飽和。並從中產生五個主題：一)醫師角度對預立醫療決定的正面評價 二) 醫師角度對預立醫療決定的負面評價 三) 醫師若面對符合臨床條件的病人如何照護 四) 醫師未來自己如果符合臨床條件如何照護 五) 醫師個人沒有參與預立醫療照護諮商的原因。
本研究發現，醫師無論是從專業角度出發或是從個人角度出發，當照顧的病人或自己面臨符合病人自主權利法的臨床情境時，除了尊重本人的意願之外，似乎更重視家屬的代理決定。連醫師自己的醫療決定甚至都需要和家人共同決定。害怕因預立醫療決定(AD)而枉死、需要先和家人討論、ACP程序麻煩、現在不是ACP的時機，是影響醫師參與自己的預立醫療照護諮商的常見因素。
結論：對部分醫師來說，預立醫療照護諮商除了尊重個人自主之外，家屬也扮演著重要的角色。以家庭為中心的醫療決策模式及關係自主，對於部分受訪醫師在考量自己的ACP有一定的解釋力。在構思促進醫師參與自己的ACP之策略時，需要納入本研究發現的影響因子。

關鍵字

預立醫療照護諮商 ； 預立醫療決定 ； 決策模式 ； 醫師 ； 質性研究

並列摘要

BACKGROUND
Advance care planning (ACP) enable a competent individual to express his/her treatment preferences. Based on those preferences, one could complete his/her advance directive (AD). If one become incompetent one day, ADs would work as the extension of patient’s autonomy in future clinical decision making. Patient Autonomy Act had been legislated on 2016/12/18 and had been enforced on 2019/1/6. Physician’s attitude toward ACP was related to the possibility of initiating ACP discussion with patients. This study aimed to investigate physician’s attitude toward ACP and potential influencing factors.
METHODS
A qualitative design was used. Participants were recruited by criterion sampling strategy. We recruited physicians who were familiar with specific clinical conditions (terminal disease, persistent vegetative status, severe dementia...) which were defined by Patient Autonomy Act. Participants were mainly oncologists, neurologists, and psychiatrists. We conducted semi-structured in-depth face-to-face interviews. All interviews were recorded, transcribed to verbatim, and subjected to editing analysis. Meaning units, subthemes and themes were developed.
RESULTS
Theoretical saturation was achieved after interviewing 16 physicians (12 male, age 32-62, median age 39.5 ). Five themes were identified: 1) benefits of ADs from the viewpoint of physician, 2) drawbacks of ADs from the viewpoint of physician, 3) how would physicians make decisions for incompetent patients with specific clinical conditions 4) how would physicians make decisions if themselves became incompetent in the future due to specific clinical conditions, 5) reasons why interviewee didn’t have his/her own ACP.
In addition to respect patient’s expressed preferences, some doctors think highly of families’ surrogate decisions either from the perspectives of physicians or themselves. If they became incompetent, some physicians would prefer letting families make decisions over completing their own ADs. We also found that many physicians expressed that they can’t complete ADs without discussion with their families. When asked why not taking their own ACPs, several influencing factors were frequently identified, including afraid of premature death due to ADs, lack discussion with families, complicated process of ACP, not good timing yet to discuss ACP.
CONCLUSIONS
When it comes to ACP, families’ opinions were not less important than personal autonomy for some physicians. Family-based decision making and relational autonomy may play roles in physician’s own ACP. Those identified influencing factors need to be addressed in order to elevate physicians’ motivation to engage in their own ACP.

並列關鍵字

advance care planning ； advance directives ； decision making ； physicians ； qualitative study

參考文獻

1. Kutner L. Due Process of Euthanasia: The Living Will, A Proposal. INDIANA LAW J.:17.

2. Wayne H, Skaggs SM. CALIFORNIA LAW REVISION COMMISSION. Published online 2000:282.

3. Annas GJ. “Culture of Life” Politics at the Bedside — The Case of Terri Schiavo. N Engl J Med. 2005;352(16):1710-1715. doi:10.1056/NEJMlim050643

4. Emanuel LL, Barry MJ, Stoeckle JD, Ettelson LM, Emanuel EJ. Advance Directives for Medical Care — A Case for Greater Use. N Engl J Med. 1991;324(13):889-895. doi:10.1056/NEJM199103283241305

5. Chung RY-N, Wong EL-Y, Kiang N, et al. Knowledge, Attitudes, and Preferences of Advance Decisions, End-of-Life Care, and Place of Care and Death in Hong Kong. A Population-Based Telephone Survey of 1067 Adults. J Am Med Dir Assoc. 2017;18(4):367.e19-367.e27. doi:10.1016/j.jamda.2016.12.066