檢視曾接受安寧療護之失智老人死亡前一年醫療利用情形:回溯性研究

Medical Utilizations for Demented Elders in Hospice During Their Last Year of Life: A Retrospective Study

陳岳君(Yueh-Chun Cheng)

指導教授 ： 許雅娟

長榮大學/健康科學學院/護理學系(所)/碩士(2016年)

摘要

晚期失智症階段會因身體功能下降及吞嚥功能喪失，可能導致失智症者增加就醫頻率與使用侵襲性醫療處置，而嚴重影響患者末期生命照護品質。有鑒於此，本研究探討曾接受安寧療護之失智症老人死亡前一年醫療利用情形以及與基本屬性之相關性。
採回溯性相關性研究法(retrospective correlation study)，樣本取自曾於南部某一醫學中心就醫的醫療紀錄，藉由病歷回溯(chart review)資料蒐集。收案條件：(1)曾於安寧病房、安寧居家接受安寧療護服務者；(2)診斷為失智症者，病歷記載國際疾病分類碼（ICD-9-CM codes）主診斷或次診斷欄位符合失智症診斷碼290.0、290.40、331.0；(3)年齡65歲（含）以上者；(4)病歷記載死亡。排除條件：(1)僅曾接受安寧共同照護個案。共81人符合收案。
結果發現曾接受安寧療護失智症老人死亡前一年平均急診就醫為2.8次(標準差=1.8)、平均住院2.7次(標準差=1.7)、平均住院日數為36天(標準差=26.5)、平均鼻胃管放置次數3.8次(標準差=3.9)。六成五到七成五失智症者未曾實施心肺復甦術、未曾使用呼吸器及不曾使用加護病房。性別與住院日數、鼻胃管放置次數、有無實施心肺復甦術、有無呼吸器使用有顯著性差異（F=9.074,p=0.004、x2=7.239,p=0.026、x2=8.412,p=0.004、x2=8.081,p=0.004）；年齡與有無實施心肺復甦術、有無呼吸器使用、有無加護病房使用有顯著差異（x2=6.972,p=0.010、x2=6.585,p=0.010、x2=5.843,p=0.016）；教育程度與有無實施心肺復甦術、有無呼吸器使用、有無加護病房使用具有顯著性差異(x2=6.427,p=0.018、x2=8.437,p=0.005、x2=12.251,p=0.001）。
針對末期失智症者高頻率急診就醫、住院；二成五至三成五失智症者仍曾接受心肺復甦術、呼吸器使用、加護病房使用之研究結果，建議應以失智症者照護需求作為接受安寧療護選擇時機，臨床醫護人員需提升失智症照護能力與失智症安寧療護概念，重視與推廣民眾及家屬在失智症早期重視安寧療護之必要性，提昇個人對於生命末期醫療選擇認知及態度，以期避免末期失智症者不必要的侵入性處置，提昇末期失智症照護品質。

關鍵字

醫療利用 ； 安寧療護 ； 末期失智症

並列摘要

The physical function decline and the loss of swallowing function occur in the late stage of dementia may result in frequent visits to the hospital and the use of invasive medical treatment that could seriously affect the quality of care in the patients’ end-of-life. In view of this, the purpores of this study was to explores the medical utilizations a year before the elderly patients with dementia who had received hospice care passed away and its correlations among the basic attributes.
The retrospective correlational study was designed.The convenient samples were recruited from the chart review of the medical records of a medical center in Southern Taiwan. Inclusion criteria were those who (1) had received hospice palliative care services in the hospice ward or home-based hospice care; (2) diagnosed with dementia using, the ICD-9-CM codes in the medical records and the primary or secondary diagnosis were in line with the diagnostic codes of 290.0, 290.40 and 331.0; (3) aged 65 years order; (4) recorded as “deceased” in the medical records. Exclusion criterion was those who had only received hospice shared care. A total of 81 participants met the inclusion criteria.
Data showed that the elders with dementia who had received hospice palliative care service had the average of 2.8 emergency department (ED) visits (SD=1.8), 2.7 times of hospitalization (SD =1.7), 36 days of hospital length of stay (SD=26.5), and 3.8 times of nasogastric tube insertion (SD=3.9) one year before their death. 65% to 75% of the dementia patients had never received cardiopulmonary resuscitation (CPR), nor had they used ventilators or ICU. There was significant difference among, length of stay in the hospital, times of nasogastric tube insertion, with or without the implementation of CPR, and with or without the use of ventilators by gender (F=9.074, p=0.004, x2=7.239, p=0.026, x2=8.412, p=0.004, x2=8.081, p=0.004). There was significant difference with or without the implementation of CPR, with or without the use of ventilators and with or without the use of ICU by age(x2=6.972, p=0.010, x2=6.585, p=0.010, x2=5.843, p=0.016). Moreover ,there was significant difference among, with or without the implementation of CPR, with or without the use of ICU by level of education (x2=6.427, p=0.018, x2=8.437, p=0.005, x2=12.251, p=0.001).
Findings reveal that the late stage of dementia patients had high frequency of ED visits and hospitalization. Approximately, 25% to 35% of them still received the implementation of CPR, the use of ventilators and the use of ICU. Findings suggest that the care needs of these patients with dementia should focus on improving knowledge aboutappropriate timing to make a decision of acceptance of hospice care. On the other hand, health care professionals need to enhance their care abilities on hospice palliative care. They need to attach importance to and enhance the concept of hospice palliative care for demented patients and their family caregivers in order to avoid unnecessary invasive medical treatments and thus to enhance the quality of care for late-stage dementia patients.

並列關鍵字

medical utilizations ； hospice care ； late-stage dementia

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