急診醫師運用病情告知模式對病人家屬簽署不施行心肺復甦術同意書的影響-壞消息告知SHARE model應用

背景:當疾病末期病人被送抵急診室時，急診醫師需要說明病情，病人家屬亦可能考量簽屬放棄心肺復甦術的聲明。然而在急診室的繁忙吵雜的照護環境中，告知壞消息對醫師是不容易的任務。SHARE model 提供告訴壞消息的重要要素。目的:本研究旨在探討急診醫師壞消息告知-SHARE model 應用，是否會對病人家屬簽署不施行心肺復甦術同意書過程與結果產生影響。方法:本研究採橫斷式研究設計，以立意取樣方式，研究資料來源包括觀察表(病情告知評分表)、問卷訪談調查(家屬訪談)及病歷回顧(次級資料)。研究對象急診求診的疾病末期且可簽屬「不施行心肺復甦術同意書」患者之家屬或其他代理人，共計145樣本數。資料使用統計分析套裝軟體SPSS 22.0 版進行分析，並以卡方分析、獨立樣本t 檢定及羅吉斯迴歸分析。結果:145位研究個案中，有簽署DNR共92人，未簽署DNR共53人。比較有簽署DNR與未簽屬DNR 兩組醫師病情告知模式程度執行情形，有簽署DNR組別之病情告知要素的設定支持性環境、如何告知壞消息、與提供保證及情緒支持的執行程度較佳。在控制病人、家屬及醫師特性變項後，如何告知壞消息與提供保證及情緒支持兩項與簽署DNR有關。結論:急診醫師病情告知-SHARE model應用，對病人家屬簽署不施行心肺復甦術同意書過程與結果達顯著影響。針對此研究結果，期望能夠提供臨床醫師在考量病人家屬於緊急情境下簽署不施行心肺復甦術同意書時做為病情說明的參考依據，並期能提升臨床照護品質。

關鍵字

不施行心肺復甦術；病情告知

並列摘要

Background: When the patient at the end of the disease is sent to the emergency department,the physician needs to explain the condition, and the family surrogates’may also consider to sign the statement of “Do- not- resuscitation”. However, telling bad news in the busy and noisy care environment of the emergency department is not an easy task for the physician.The share mode provides important elements to tell bad news. Purpose: The purpose of this study was to investigate the application of the Share model in emergency physician’s delivery bad news to determine whether it will have an impact on the process and results of family surrogates’signing DNR. Methods: This study adopts a cross-sectional study design and purposive sampling method.The study data sources include observation charts (information notification scales),questionnaire interviews (family interviews), and medical records review (secondary data).Subjects are patients who visits emergency department with condition of the terminal stage of the disease eligible for singing DNR and their families and delegates, for 145 subjects. Data were analyzed using statistical analysis software SPSS 22.0 and analyzed by Chi-square analysis, independent sample t-test, and Logistic regression analysis. Results: There are 145 study subjects. Of 92 subjects sing DNR and the other 53 subjects do not sign DNR. Comparing the implementation status of the two groups of physicians' performances in telling bad news mode, the supportive environment, how to deliver the bad news, and reassurance and emotional support are better implemented. After controlling the characteristics of patients, their families, and physicians, how to deliver the bad news and reassurance and emotional support are related to signing DNR. Conclusions: Emergency physicians inform patient's conditions thru Share model, had profound effect on family surrogates’ sign “Do -not- resuscitate” form. This research provides clinical physicians a reference for during critical conditions to guide family surrogates’ sign “Do- not- resuscitate” order, with hope to elevate overall clinical care quality.