分析影響透析病人末期照護選擇之因子：以南部某區域教學醫院為例

Explore the Factors Affecting the End-of-Life Care in Dialysis Patients at a Teaching Hospital in South Taiwan

陳俊旭(Jean-Shi Chen) ； 葉宏明(Horng-Ming Yeh) ； 高以信(Yee-Hsin Kao)

《台灣老年醫學暨老年學會雜誌》 16卷1期 (2021/02) Pp. 29-42

https://doi.org/10.29461/TGGa.202102_16(1).0003

摘要

目的：本研究目的在探討本院透析病人生命末期照護選擇之因子，並比較簽署DNR與否造成之差異。方法：採電子病歷回溯性調查本院2年內曾住院並接受透析最後死亡之病人共191人。調查項目包括病人基本資料、最後一次住院之實驗室資料、最後一次住院之基本狀態、死亡前之相關指標共37細項。分成有簽署DNR（117人）及無簽署DNR（74人）兩組統計分析比較。結果：共191人，有簽署DNR組117人、無簽署DNR組74人。平均年齡75.2歲（SD 11.3），而≥65歲者佔83.3％。在兩組37細項比較發現有顯著意義包括接受心肺復甦術（有簽署組比無簽署組15.5％比43.8％，P值0.000）、放置氣管內管（37.6％比58.1％，P值0.006）、臨終前撤除透析治療（18.8％比5.4％，P值0.030）。回歸分析發現影響臨終前撤除透析治療與否之相關因素包括透析時間之增加、血清白蛋白下降、有心衰竭病史、使用呼吸器、以及有簽署DNR。同時亦發現血中肌酐酸愈低、完全生活依賴度（ECOG=3，4）、無氣管插管、無接受心肺復甦術、臨終前撤除透析治療與簽署DNR有關。結論：透析病人有無簽署DNR與接受心肺復甦術，接受氣管內管插管，以及臨終前撤除透析治療三項有顯著的相關。推究原因可能是安寧團隊介入後，經過溝通與陪伴，影響透析病人末期照護選擇。

關鍵字

生命末期照護 ； 撤除透析治療 ； 不施行心肺復甦術

並列摘要

Objective: The purpose of the study is to explore the factors affecting the end-of-life care in dialysis patients in our hospital and compare the differences between patients with and without DNR. Methods: A retrospective investigation was conducted on 191 patients who passed away in the last two years after receiving dialysis at our hospital. The survey included basic demographic information, laboratory data, basic clinical information of the last hospitalization, and related indicators of end-of-life care. Patients with DNR (117) and without DNR (74) were then compared for exploring the factors affecting end-of-life care using SPSS for window 22. Results: The 191 subjects reported an average age of 75.2 years old, and 83.3% of them were 65 years and older. After comparing the two groups of subjects, cardiopulmonary resuscitation (with DNR vs. without DNR 15.5% vs. 43.8%, p=0.000), placement of the endotracheal tube (37.6% vs. 58.1%, p=0.006), and end-of-life withdrawal from dialysis (18.8% vs. 5.4%, p=0.030) emerged as significant factors. Results of regression analysis indicated that decision to withdraw dialysis were affected by increase in dialysis time, decline in serum albumin, history of heart failure, use of respirators, and signing of DNR. Lower blood creatinine, complete life dependence, no endotracheal intubation, no cardiopulmonary resuscitation, and withdrawal from dialysis were found to significantly affect DNR signing. Conclusion: Intervention of the palliative care team that increases the time of communication with dialysis patients and their family members appear to be a major factor affecting end-of-life decision.

並列關鍵字

end-of-life care ； withdrawal from dialysis ； do not resuscitate (DNR)