比較北部與東部加護病房病患簽署不施行心肺復甦術同意書對臨終前醫療處置影響之差異

A Comparison of Differences in Medical Treatments Patients with Do-not-resuscitate Orders Received Before Death in the Intensive Care Units in Northern Taiwan and Eastern Taiwan

莊艷妃(Ian-Fei Juang) ； 黃錦鳳(Chin-Feng Huang) ； 黃雅庭(Ya-Ting Huang)

《慈濟技術學院學報》 24期 (2015/03) Pp. 1-18

摘要

背景：由於現代人對科技的種種迷思、認為人定勝天，導致醫療科技延長死亡歷程，讓病患遭受到不必要的醫療處置及痛苦。台灣於2000年通過「安寧緩和醫療條例」，醫界亦將此條例運用於加護病房末期病患照護，期待藉著末期病患或家屬簽署不施行心肺復甦術（Do Not Resuscitate，DNR）同意書，讓末期病患臨終前免於遭受不必要的治療、得到善終。為了解DNR同意書對加護病房病患臨終前接受醫療處置的影響及城鄉運用之情形，故進行本研究。目的：比較北部及東部醫學中心加護病房有DNR同意書末期病患於臨終前接受醫療處置的差異。方法：採回溯調查法。以北部及東部之某醫學中心住成人內外科加護病房死亡或病危、留一口氣回家且有DNR同意書病患的病歷為主要研究對象，以自擬結構性調查表進行資料收集及統計，共調查254位，其中北部佔133位、東部121位。結果：本研究發現北部有DNR同意書病患的平均年齡高於東部病患5歲（p＜0.001），住加護病房平均天數也較東部增加4.14天（p＜0.05），而離開加護病房原因，北部以死亡居多，佔74.4%，而東部則以病危、留一口氣出院為主，佔66.1%。比較北部與東部醫學中心加護病房有DNR同意書病患於臨終前48小時接受延命醫療處置有統計上差異的項目包含：急救藥物、輸血及白蛋白輸注治療、點滴輸液、插氣管內管或氣切、抗生素治療、放射線檢查、生化檢查（p＜0.05~0.001）；比較北部及東部病患臨終前不予醫療處置有統計上差異的項目包含：血管升壓藥物、急救藥物、體外心室救助治療、心臟人工調頻治療、心臟電擊、心臟按摩（p＜0.001）。結論：本研究結果發現北部病患在臨終前48小時接受延命醫療措施的比例高於東部病患。另外，北部病患在臨終前不予醫療處置的比例也高於東部病患，但是不予醫療處置的項目侷限在心肺復甦術的項目。顯示末期病患臨終前的照護品質仍有待改善。

關鍵字

不施行心肺復甦術 ； 加護病房 ； 生命末期

並列摘要

Background: Modern people hold myths towards technologies, and think that man can conquer nature. Therefore, medical technologies are employed to extend death process so that patients often suffer from unnecessary medical treatments and pain. The Hospice and Palliative Care Act was passed in Taiwan in 2000, and the medical professions have actively applied it to the care for terminally ill patients in the intensive units. It is expected that terminally ill patients can avoid unnecessary treatments and die a peaceful death through the signature of do-not-resuscitate (DNR) order by themselves or their family members. The study aimed to investigate how DNR orders influenced the medical treatments that patients received before death in the intensive care units (ICUs) and how DNR orders were employed in cities and countries. Objectives: To compare the differences in medical treatments patients with DNR orders received before death in the ICUs in the medical centers in northern Taiwan (NTW) and eastern Taiwan (ETW). Methods: Retrospective survey was conducted for this study. A convenience sample of 254 subjects was enrolled. The main subjects were those who had signed DNR orders, and expired or were discharged due to terminal status (DDT) from medical and surgical ICUs in the medical centers in NTW and ETW. Self-designed structured questionnaires were used for data collection and analysis. Among the total of 254 patients, 133 were from NTW and 121 from ETW. Results: The results showed that the mean age of NTW patients with DNR orders were 5 years (p ＜ 0.001) older than ETW ones. Intensive-care-unit stay for NTW patients was 4.14 days longer than ETW ones (p＜0.05). Death was the major reason of leaving ICUs for NTW patients (74.4%), while DDT was the main reason for most of ETW patients (66.1%). Statistically significant differences found in the comparison of life-support treatments patients with DNR orders received 48 hours before death in the ICUs in the medical centers in NTW and ETW were resuscitative drugs, blood transfusion, albumin transfusion therapy, intravenous fluids, endotracheal intubation or tracheostomy treatment, antibiotic therapy, radiolgy examination, and blood sampling for laboratory examination (p ＜0.05~0.001). As for the comparison of withholding of treatments before death, statistically significant differences were found in vasopressors, resuscitative drugs, salvage therapy with ventricular assist device, pacemaker, defibrillation, and cardiac massage (p ＜0.001). Conclusion: The results of this study found that NTW patients showed a higher percentage than ETW ones in receiving life-support treatments 48 hours before death. In addition, NTW patients also had a higher percentage than ETW ones in withholding life-support treatments before death; however, withholding therapy only included CPR. This indicated that the quality of end-of-life care for terminally ill patients still needs to be improved.

並列關鍵字

Do-not-resuscitate (DNR) ； Intensive care unit (ICU) ； Terminal