偏鄉醫院醫護人員對病人自主權利法與預立醫療照護諮商之知識、態度與行為

背景與目的：2019年1月6日施行《病人自主權利法》（以下簡稱病主法），是台灣首部以病人為主體的法案，目的是尊重病人醫療自主權，保障善終權益促進醫病關係和諧，保障每個人知情、選擇、接受或拒絕醫療的權利，確保病人善終意願。透過預立醫療照護諮商(advance care planning, ACP)、簽署預立醫療決定(advance directives, AD)，行使醫療自主權。醫護人員的知識、態度會在病人對病人自主權利法及ACP的看法與行為扮演重要角色，因此本研究旨在探討中部某公立區域教學醫院醫護人員對病人自主權利法與ACP知識、態度與行為之現況、相關影響因素與關聯性。方法：本研究經IRB審查核准後，以中部某公立區域教學醫院醫護人員為研究對象，採橫斷結構式問卷調查研究，總計發放387份，共回收355份問卷。問卷內容包括基本特性、病人自主權利法及ACP知識、態度與行為。統計分析包含敘述統計、t檢定、單因子變異數分析及多元複迴歸分析。結果：醫護人員對ACP的知識程度較高，標準化得分平均為86.29分，但對病主法的知識程度卻較低，標準化得分平均為60.22分。對ACP、AD與病主法的態度也朝向正面，但對ACP與AD的障礙較高，ACP信心與支持體系較低，對於參與ACP討論意願與實行ACP的行為較正面。參與過安寧緩和醫療專業訓練之醫護人員對病主法知識顯著較高。工作年資較高、簽署過DNR或安寧緩和意願書者對ACP與AD態度較高；護理人員對ACP與AD障礙較高；健康狀態非常好者、曾參與病主法專業訓練者，其實施ACP的信心與實施ACP支持體系顯著較高；女性、主治醫師、健康狀態好、有照顧親友經驗者、曾接受安寧緩和醫療專業訓練者，其參與ACP的意願與實行ACP行為顯著較高。醫護人員ACP知識對態度呈現顯著正向影響，與ACP支持體系呈現顯著負向影響。病主法知識對態度及參與ACP意願呈現顯著正向影響，對ACP信心呈現顯著負向影響。醫護人員病主法與ACP態度對參與ACP意願及實行ACP行為呈現顯著正向影響。結論：醫護人員對病人自主權利法知識不足，但對ACP知識程度高，而在態度方面則朝向正向，但因障礙較高、信心較低，實際簽署率較低，可見應加強相關資訊的提供、教育訓練及溝通技巧訓練課程，使醫護人員在推行或臨床操作上能更加得心應手。

關鍵字

醫護人員；病人自主權利法；預立醫療照護諮商；預立醫療決定；知識；態度；行為

並列摘要

Background and objectives: The Patient Self Determination Act(PSDA), implemented on January 6, 2019, is enacted with the aim to respect patients’ autonomy in healthcare, safeguard their rights to a good death, promote a harmonious physician–patient relationship, protect patients’ rights to know, choose, accept, or refuse medical treatment, and ensure that patients’ end-of-life wishes are granted. The act is Taiwan’s first-ever patient-based act and enables patients to exercise autonomy in healthcare by participating in advance care planning (ACP) and signing advance directives (AD). The knowledge and attitude demonstrated by healthcare staff have a profound effect on how patients view PSDA and ACP and how they engage in subsequent related behavior. Accordingly, this study investigated the current PSDA and ACP knowledge, attitude, and behavior of healthcare staff in a public regional teaching hospital in central Taiwan; relevant factors of influence; and the effect of said knowledge, attitude, and behavior on how patients viewed PSDA and ACP and how they engaged in subsequent related behavior. Methods: Upon being reviewed and approved by an IRB, this study selected healthcare staff in a public regional teaching hospital in central Taiwan as the study participants and conducted a cross-sectional survey using structured questionnaires. A total of 387 questionnaires were disseminated, of which 355 were returned. The questionnaire contained data including the participants’ demographic information as well as PDSA and ACP-related knowledge, attitude, and behavior. Subsequently, statistical analyses, which included descriptive statistics, t test, one way ANOVA, and multiple regression analysis, were performed. Results: The healthcare staff were well-versed in ACP, producing an average standard score of 86.29. By contrast, they were not well-versed in PDSA, producing an average standard score of 60.22. They showed a positive attitude toward ACP, AD, and PDSA; were willing to participate in ACP discussions; and demonstrated positive ACP-related behavior. However, they encountered relatively more ACP and AD-related barriers; were less confident with ACP; and had less ACP-related support system. Healthcare staff who received hospice and palliative care training were significantly more well-versed in PDSA. In addition, healthcare staff who had worked longer at the hospital; patients who had signed a do-not-resuscitate order, and patients who had signed a letter of intent for hospice and palliative care displayed more positive attitude toward ACP and AD. Healthcare staff encountered relatively more ACP and AD-related barriers. Those who had received professional PDSA training were more confident in practicing ACP and perceived ACP support systems more frequently. Females, attending physicians, those who were well health and had experience caring for relatives and/or friends, and those who had received hospice and palliative care training were significantly more willing to engage in ACP. Healthcare staff’s ACP knowledge exhibited a significant and positive association on their ACP attitude, and a significant and negative association on ACP support system. PDSA-related knowledge and attitude exhibited a significant and positive association on willingness to engage in ACP, and a significant and negative association on confidence in ACP. Healthcare staff’s attitude toward PDSA and ACP exhibited a significant and positive association on their willingness to engage in ACP and their actual engagements in ACP. Conclusion: The healthcare staff in this study were well-versed in ACP but not PDSA. Although they displayed a positive attitude toward ACP, the relatively challenging barriers encountered and their lack of confidence in ACP resulted in less patients signing the AD. Thus, relevant information, education, training, and communication skill-oriented training courses should be provided to enable healthcare staff to promote and implement ACP and AD more effectively in clinical practice.