預立醫療照護計畫對老人與潛在代理人於末期照護偏好一致性之探討

研究背景：老人的年齡和健康狀況常使老人成為無能力決策的高風險群。當老人失去決策能力時，家人經常代替老人做決策。然而，多數的文獻指出家人並不清楚老人對末期照護的偏好且預測能力差。研究目的：探討預立醫療照護計畫(advance care planning; ACP)對提升老人與潛在代理人於末期照護偏好之一致性。研究設計：採類實驗-雙組前後測設計。研究對象：採立意取樣(purposive sampling)，針對某醫學中心之兩個高齡病房年齡大於65歲的老人和其潛在代理人。測量工具：以生命支持偏好問卷(life support preferences questionnaire; LSPQ)做為主要成果指標。介入措施：利用本研究所發展之「高齡預立醫療照護諮商」衛教手冊與老人和其潛在代理人進行結構性討論，內容包括：「認識預立醫療照護諮商與預立醫療決定」、「什麼是您想要的醫療照護」、「預立醫療照護諮商的討論」，平均時間約28分鐘。結果：老人對於LSPQ上之四種醫療處置，僅抗生素的使用在目前健康狀況、嚴重失智和持續性呼吸困難的情境有超過2.5分(範圍1-5分)，也就是說傾向在這三種情況下使用抗生素；其餘老人對於心肺復甦術、手術和鼻胃管灌食皆傾向不使用。研究中的潛在代理人可以預測老人對心肺復甦術的想法；以及預測老人對手術的想法，在九種情境中，僅在嚴重中風合併不可能改善和癌症末期合併嚴重疼痛的二種情境下，與老人想法顯著不同。此外，潛在代理人無法準確預測老人對於抗生素和鼻胃管灌食的想法。透過逐步線性迴歸分析控制其他變項的影響後，發現組別、老人教育程度、老人子女數、潛在代理人與家人溝通預立醫療指示(advance directives; ADs)的願意，以及潛在代理人的身分會影響老人與潛在代理人對末期照護偏好的一致性。結論與建議：本介入措施可以提升老人和潛在代理人對末期照護偏好之一致性。老人族群有其特殊性，建議發展更多適合老人的讀物或多媒體，以增加老人對末期醫療的認識和促進預立醫療照護計畫的討論。此外，未來研究可以增加潛在代理人如何做「代理決策」的比較。

關鍵字

老人；潛在代理人；末期照護；偏好；預立醫療照護計畫；預立醫療照護諮商；預立醫療指示；預立醫療決定

並列摘要

Background: Older people’s age and health condition often made them to be a high risk of incapacity. Family members always substituted for older people to make decisions when they lost capacity. However, studies indicated that family members did not know older people’s preferences toward end-of-life care, and family members’ ability for prediction was poor. Aim: The aim of study was to explore advance care planning on agreement about the preferences of end-of-life care between older people and their potential surrogates. Design: Pretest-posttest control group design was adopted in the study. Participants: Older people with age over than 65 years old and their potential surrogates were recruited at two geriatric wards in a medical center. Measurement: The 36 items of life support preferences questionnaire (LSPQ) was the major measuring tool which includes four medical measures in nine scenarios. Intervention: The brochure of “advance care planning for seniors” was developed for older people. The content of the brochure included three parts: “familiar with advance care planning and advance decision”, “willingness in your medical care”, and “discussion in advance care planning”, separately. During the process of intervention, the researcher would go through this brochure with older people and their potential surrogates to stimulate them to have their own discussion about end-of-life care. The average time of intervention was 28 minutes. Results: Older people only agreed with antibiotics applied on current health, severe dementia, and continuous dyspnea, while older people tended to decline cardiopulmonary resuscitation (CPR), surgery, and nasogastric tube feeding used in all scenarios. Potential surrogates could predict older people’s preferences about CPR in all scenarios, and only could not predict preferences about surgery in two of nine scenarios, which were severe stroke with no recovery and terminal cancer with severe pain. Additionally, potential surrogates had poor prediction about older people’s preferences for antibiotics and nasogastric tube feeding. Using stepwise liner regression model to control other variables, the results showed that “group”, “educational level of older people”, “numbers of children of older people”, “potential surrogates’ own willingness to discuss advance directives (ADs) with family members”, and “relationships of potential surrogates to older people” would affect an agreement about the preferences of end-of-life care between older people and their potential surrogates. Conclusions and suggestions: The intervention could improve an agreement about the preferences of end-of-life care between older people and their potential surrogates. The study suggests that more brochures or media related to advance care planning should be developed based on older people’s specific characteristics, such as cognition or sensory function degradation. In addition, what potential surrogates would make “substitute decision” for older people could be compared in the future study.

並列關鍵字

older people ； potential surrogates ； end-of-life care ； perferences ； advance care planning ； advance directives ； advance decisions

參考文獻

蔡甫昌、潘恆嘉、吳澤玫、邱泰源、黃天祥(2006)．預立醫療計畫之倫理與法律議題．臺灣醫學，10(4)，517-536。doi: 10.6320/fjm.2006.10(4).15

Tavakol, M., & Dennick, R. (2011). Making sense of Cronbach's alpha. International Journal of Medical Education, 2, 53-55. doi: 10.5116/ijme.4dfb.8dfd

王业兴(2008)清末民初的教育新理念与孙中山近代化教育思想．甘肅社會科學，2008(3)，164-166。