某醫學中心安寧療護轉介時機之探討

The Timing of Terminal Patient Referral to Hospice Palliative Care in a Medical Center

王素鴻(Su-Hung Wang)

指導教授 ： 白佳原

中山醫學大學/醫學院/醫學研究所/碩士(2010年)

摘要

目的：適當的醫療決策對醫護人員轉介末期病人接受安寧療護是現今醫療決策時機的挑戰。面對日以漸增的癌症死亡人數，全面提升癌症末期病人與家屬的生活品質，以成為現今醫療提供者刻不容緩的重要議題。因此希望藉由本研究提供臨床實務者轉介安寧療護時機之易於執行醫療決策的參考因素。
方法：本研究分析中部某醫學中心西元2004年至2006年死亡病人之資料，篩選整理在院死亡及病危出院而48小時內死亡的癌症病人，共計樣本數有896人。採敘述性統計、卡方檢定及Logistic Regression Analysis，探討病人屬性、病情程度及轉介安寧共同照護之狀態與轉介安寧療護時機的關係。
結果：發現病人平均年齡63.5歲，以60-79歲居多（51.5％），性別以男性較多(63.8％)。肝癌（18.9％）及肺癌（18.5％）為前兩大癌症。47％以上有遠處轉移。病人最後由門診而住院的佔62.2％。而病危出院後死亡則高達70.3％。癌症病人死亡之安寧涵蓋率佔48.7％，轉介安寧共同照護比率為41.1％，轉入安寧病房比率為23.5％，接受安寧居家療護比率為3.1％。轉介科別以內科（85％）為主，轉介時病人身體活動功能評估指標（KPS）：40分（28.3％），活動能力評估表（ECOG）：3級（54.3％）。整體癌症病人平均存活期181天以上佔51.8％。曾轉介安寧共同照護之癌症病人，診斷至死亡的存活期為613天，比起沒有轉介的癌症病人（510.9天）有較長的存活期，而曾接受安寧病房之癌症病人，診斷至死亡的存活期為574.6天，較未接受安寧病房照顧的病人多出近20天，安寧療護在延長存活天數是有顯著差異。轉介安寧共同照護後7天內死亡的病人佔39％（轉介日至死亡日之平均存活期為37.2天），另轉入安寧病房後7天內死亡的病人佔49％（轉入日至死亡日之平均存活期為33.5天），顯示轉介安寧療護時機皆偏晚。
結論與建議：對於轉介安寧療護時機有三項（年齡、遠處轉移、科別）因素有顯著影響，在Logistic Regression R square 係數為0.07。另外對於存活分期與癌症病人年齡、診斷、遠處轉移亦有顯著差異，在Logistic Regression R square 係數則為0.06。分析發現轉介安寧共同照護與否對癌症病人的存活期是有差異且有正相關，且在轉介安寧共同照護後的存活分期與病人身體功能狀態，ECOG 有顯
著負相關（Spearman=－0.39)，KPS 有顯著的正相關（Spearman=0.46)。
此研究結果提供醫護人員對評估轉介安寧療護時機有進一步認識，建議可在適當時機提供安寧療護資訊及轉介服務，透過適切的醫療決策及種種的障礙協調，盼能讓末期病人善終及其家屬無憾。

關鍵字

安寧療護 ； 緩和醫療 ； 末期病人 ； 轉介時機

並列摘要

Purpose： The purpose of this study is to set up criteria of the right referral time of hopice care for clinical workers. Since the death number of cancer patients is
increasing dramatically, the way to improve the life quality of terminal cancer patients and their families is an important for healthcare issue to the medical providers now. The major challenge to a medical team nowadays is to make a right medical decision at right time in referring terminal patients to hospice care.
Methods: Sample analyzed the expired patients’data in a medical center in Taichung during 2004 to 2006. Screening the expired patients in the hospital and discharging on critical condition, but in 48 hours die cancer patient. The total samples size is 896. The descriptive statistics, Chi-square test, and regression analysis is used to analysis the data on the attribute of patients, their condition stages, referral states of hospice combine care and the referral timing of hospice care.
Results: The average of patients’age is 63.5 years old, the age between 60 to 79 years old is 51.5%, male (63.8%), HCC（18.9%）, lung cancer（18.5%）, 47% of patients have distant metastasis, and outpatients admitted to hospital is 62.2%. For discharging on critical condition, the patient death rate is 70.3%. The death rate of hospice care for cancer patients is 48.7%. In the expired patients, the cover-rate of hospice combine care is 41.1%; the cover-rate of hospice ward care is 23.5%; and the cover-rate of hospice home care is 3.1%. Internal medicine is the main department of referring patients to hospice care (85%). The KPS of those patients of hospice combine care is 40 degree (28.3%), and the ECOG is 3 degree (54.3%), the average survival days of all patients is over 181 days (51.8%). The average survival days from diagnosis to death of cancer patients who did not been referred to hospice care is 510.9 days, and average survival days of the cancer patients who were referred to hospice combine care is 613 days. The survival days of cancer patients who were referred to hospice ward care (574.6 days) is higher than those who did not been referred to hospice ward care. Hospice care has significant for the survival days longer. The average of survival days from the date of referring to hospice combine care to death date is 37.2 days. However, the rate of patients who expired in 7 days after referring to hospice combine care is 39%. The average of survive days from the date of referring to hospice ward to death date is 33.5 days. The rate of patients who expired in 7 days after referring to hospice ward care is 49%.
Conclusion and Suggestion: Acording to the result, the hospice care referral timing of the patients is too late. The results of this study can provide further information for the healthcare providers to assess the referral timing of hospice care. There are three significant factors “ages, distant metastasis and the medical departments” related to the referral timing of hospice care, and the Cox & Snel R square coefficient of the logistic regression model is 0.07. There are three significant factors “cancer patients’ ages, diagnosis, and distant metastasis” related to the stage of survival time, and the adjusted R square coefficient of the regression model is 0.06.
Also, the study suggests that the healthcare providers supply the hospice care information to patients and their families and refering hospice care in the right time by
proper medical decision-making and communication, to improve the quality of life for terminal patients and their families.

並列關鍵字

Hospice ； Palliative Care ； Terminal Patient ； Referral Timing

參考文獻

王英偉(2009)·安寧緩和醫療臨床工作指引·台北：安寧照顧基金會。

吳宜芳 (2005) ·探討加護病房家屬對疾病末期病人醫療決策行為意向及其影響因素 · 未發表的碩士論文，臺灣大學護理學研究所。

吳美幸 (2009) ·家屬對病人入住安寧病房的決策經驗·未發表的碩士論文，長榮大學護理學研究所。

高綺吟、邱泰源、胡文郁、陳慶餘、賴明坤、陳月枝 (2007) ·癌末病人安寧共同照護之照會·臺灣醫學，11（6)，602-611。

莊榮彬 (2005) ·安寧共同照顧簡介·安寧療護，10 (1)，39-43。