社區高齡者預立安寧意願：以懷舊團體工作為媒介之探討

A Study on Community Senior Citizens’ Intent to Sign an Advance Hospice Palliative Care Form:A Case of Reminiscence Group Work

城瑞蓮(Ra-Lien Cheng)

指導教授 ： 杜承嶸

長榮大學/人文社會學院/社會工作學系(所)/碩士(2016年)

摘要

本研究以「社區高齡者預立安寧意願:以懷舊團體工作為媒介之探討」為主題，透過探究如下問題：
1.高齡者的年齡、教育等背景及生命經驗對其預立安寧意願的影響為何?
2.懷舊團體工作是否能促發及協助高齡者追求自己的善終權?
3.透過行動研究評估懷舊團體工作是否能成為促發高齡者追求自我善終權的模式?
來探討影響高齡者預立安寧緩和醫療意願的因素、懷舊團體工作能否成為一個促發及協助高齡者追求自己善終的權益的可能模式。
本研究以質性研究為主，量化研究為輔，在社區以行動研究作為懷舊團體工作運作及修正的依據，在收集資料的部分，除了讓成員於懷舊團體中分享其對預立安寧意願的理解及看法，也以觀察法之參與觀察於團體活動，對參與對象進行觀察同時做紀錄，並以自製問卷及半結構訪談大綱進行調查及訪談，作為資料的蒐集，最後將文本內容做資料的分析及量化的統計，再以三角檢測讓研究具嚴謹度。
研究發現受訪者的生命經驗中有照顧過末期病人的對預立安寧意願的實踐多數有深切的影響，80歲以上的高齡者對簽署預立安寧意願書有較高的意願；性別、婚姻狀況、居住狀況、經濟狀況及宗教信仰的不同，對預立安寧意願並無明顯的不同，然而，透過融入安寧理念的懷舊團體工作引導，成員對預立安寧意願的認同度均有提升。
若以計畫行為理論的觀點來看，作為「實際行為控制」的懷舊團體工作能提升預立安寧意願的「行為意向」，進而使其進行「簽署預立安寧意願書」或「與親人談論預立安寧意願(醫療自主計畫) 」等行為，然而，預立安寧意願書的兩個見證人欄位，卻是簽署「預立安寧緩和醫療暨維生醫療抉擇意願書」後註記到健保卡的絆腳石，以至於預立安寧意願的「主觀規範」(高齡者的重要家人支持與否)直接影響「註記安寧意願到健保卡」的行為。
研究建議:
一、結合社區樂齡中心、關懷據點、日照中心對高齡者施以融入安寧理念的懷舊團體工作，讓高齡者有機會預作醫療自主計畫，能在臨終時拒絕無效醫療，保障其善終權。
二、邀請高齡者親人參與懷舊團體工作，增進親人溝通管道，破除高齡者預立安寧意願書後執行之阻力，實現高齡者之善終權。
三、提升醫護人員安寧療護之觀念，在病人臨終急診時，能善盡醫病溝通，協助高齡者實現其安寧意願，保障其善終權。
四、修改法令讓它能真正落實意願人自主權之保障，以維護高齡者善終權之自主。

關鍵字

預立安寧意願 ； 醫療自主計畫 ； 懷舊團體工作 ； 計畫行為理論

並列摘要

This study’s subject is “A Study on Community Senior Citizens’ Intent to Sign an Advance Hospice Palliative Care Form: A Case of Reminiscence Group Work”. It aims to explore the following questions:
1. How do the age, education, life experience, etc., of a senior citizen affect his/her willingness to sign an advance hospice palliative care form?
2. Can reminiscence group work prompt and help senior citizens to pursue their own end-of-life rights?
3. Through action research, we assessed whether reminiscence group work can become a model for prompting senior citizens to pursue their own end-of-life rights.

Then, we discussed the factors that affect senior citizens’ willingness to sign an advance hospice palliative care form, as well as whether reminiscence group work can become a feasible model for prompting and helping senior citizens to pursue their own end-of-life right.
This is a qualitative study accompanied by quantitative research. In community, action research served as a basis for operations and revisions of reminiscence group work. In respect of information gathering, members were encouraged to share their understandings and views on the intent to sign an advance hospice palliative care form in the reminiscence group. An observation method was adopted to observe and document group activity and participants. Moreover, a self-made questionnaire and a semi-structured interview outline were utilized for a survey and interviews to gather information. Finally, an analysis was undertaken on the content of the information, and a quantitative statistic compilation was conducted, accompanied by a triangulation test for a rigorous research.
The study has found that interviewees who had ever taken care of terminally ill patients in their life experience were more willing to sign an advance hospice palliative care form, in particular for elderly citizens who are over 80 years old. Gender, marital status, living condition, economic condition, and religious belief have no significant effect on the intent to sign an advance hospice palliative care form. Nevertheless, through the guidance of a reminiscence group by introducing a hospice concept, members’ identification with the intent to sign an advance hospice palliative care form has increased.
In terms of theory of planned behavior (TPB), reminiscence group work which serves as “actual behavior control” can increase the “behavioral intention” of the intent to sign an advance hospice palliative care form, and further let them sign an advance hospice palliative care form, or talk about the intent to sign the advance hospice palliative care form with their family (advance care planning (ACP)), etc. However, the fields of two witnesses to signing an advance hospice palliative care form are a stumbling block to make a note on the health insurance card after signing the Advance Hospice Palliative Care & Life-Sustaining Treatment Choices of Intent form. And the subjective norm (whether the important family members of the elderly patient support or not) for signing the advance hospice palliative care form directly affects the behavior of making a note of hospice intent to the health insurance card.
Suggestions from this research:
1. Collaborate with the community senior learning center, care stations, and day care centers, by introducing hospice care to reminiscence group work for senior citizens, to let them have a chance to make ACP, and reject ineffective treatment in their last breath, to ensure right to die a natural death.
2. Invite senior citizens’ family to take part in reminiscence group work to facilitate the communication channel with family, exclude the resistance of execution after senior citizens sign an the advance hospice palliative care form, and implement their right to die a natural death.
3. Enhance medical personnel’s hospice care concept to help to communicate between the doctor and the patient, assist senior citizens to implement their hospice intent, and ensure their end-of-life rights.
4. Amend law and regulation to really insure patient autonomy for the person of intent to insure senior citizens’ right to die naturally.

並列關鍵字

Advance Hospice Intent ； Advance Care Planning ； Reminiscence Group Work ； Theory of Planned Behavior

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