醫師提出終止透析決策之影響因子分析

Factors Associated with Proposing Dialysis Withdrawal for Critically Ill ESRD Patients – Physicians’ Perspectives

張厚台(Hou-Tai Chang)

指導教授 ： 陳端容

國立臺灣大學/公共衛生學院/醫療機構管理研究所/碩士(2010年)

https://doi.org/10.6342/NTU.2010.00918

摘要

末期腎病須要慢性透析的病人族群的增加已成為全世界健康照護系統的挑戰, 除了預防腎功能的變化導致透析, 避免不必要、無效的透析治療更是重要的議題。尤其是重症的慢性透析病患何時該建議退出透析, 這方面的文獻資料闕如, 所以我們的研究主要在了解影響醫師同意撤除透析的相關因子。
我們設計了一分情境式問卷, 模擬一個老年失智的慢性透析病例會面臨的五個臨床情境,以滾雪球模式發放了275分問卷給具照顧慢性腎病病例經驗的醫師。針對問卷中的五個情境各敘述了十個問題, 將醫師對各個情境最終的同意情形對醫師的基本變項資料做卡方檢定, 再將情境中各構面問題的同意程度做邏輯式迴歸, 以p<0.05 表統計學顯著相關。
249名醫師完成了問卷, 其中有效的問卷為240分, 回收率90.5%, 針對情境一描述老年失智的慢性透析患者, 僅14%的填答醫師同意在情境一建議退出透析,醫師同意建議撤除透析的比例在情境三當家屬也同意撤除透析時最高, 達86.4% 。在不同的病人情境下, 影響醫師同意終止透析建議的基本資料變項不同, 包括: 工作所屬醫院在北部(情境一、四)、工作性質為住院醫師(情境三、四) 、執業科別為胸腔暨重症科(情境三) 、主要工作地點在加護病房(情境四)、過去一年內曾有建議退出透析的經驗(情境三至五) 及醫師性別為女性皆會顯著增加同意退出透析的機會。邏輯式迴歸分析顯示, 醫師的專業判斷及病人年紀對醫師決策終止透析影響最大。醫師的基本資料變項亦會影響醫師在不同情境考慮的構面因素,影響程度不一。顯示醫師的決策是否同意提出終止透析的建議,隨著醫師的背景資料及病患的情境而定, 是一個動態的過程。
本研究發現醫師的決策過程隨病患不同的病況情境而變化, 影響因子也隨之改變, 所以根據本研究發現的影響因子, 建議進一步做相關的教育計劃, 訓練年輕醫師針對不同病患情境, 何時可考慮退出透析及相關考慮因素, 以對末期腎病的重病病患達更好的末期生命照護。

關鍵字

終止透析 ； 末期腎病 ； 重症病患 ； 決策 ； 末期生命照護

並列摘要

Background: The increasing prevalence of end stage renal failure patients is challenging in health care system around the world. In addition to prevention of the dialysis initiation, it is important in dialysis withdrawal if proven futile. Few data is available about factors associated with proposal of dialysis withdrawal for critically-ill ESRD patients. We therefore studied physician’s views and factors influencing physician’s decision-making on dialysis withdrwal.
Methods: We surveyed 275 physicians who were experienced in care of ESRD patients about their views on dialysis withdrawal. One hypothetical case with five clinical scenarios was included. Participants score their responses according Likert scale as a report to agree/disagree with the 10 statement within each scenarios. Participants’ demographic data were recorded. The correlation of demographic data to agreement of each scenario was calculated with chi-square test. The association of agreement to each statement was calculated with logistic regression method. It is statistically significant when p<0.05.
Results : Of 275 physicians, 249 completed surveys and 240 effectively returned . Fourteen percent of physicians agreed to withdraw dialysis in scenario one when clinical information of the hypothetical ESRD patient with old age and dementia. Highest agreement ( 86.4%) was achieved in scenario three when families responded agreement to dialysis withdrawal. There are different demographic factors associated with dialysis withdrawal proposal in each scenario are hospital at northern Taiwan (scenario 1,4)、level of training(Scenario 3,4)、subspecialty(scenario 3)、ICU full-time physician(scenario 4)、experience of proposal of dialysis withdrawal in the preceeding year(scenario 3-5) and gender (scenario 5). Logistic regression result showed physician experts ( his/her own opinion) possessed the most important consideration (odds ratio: 2.908, 2.617, 2.970, 2.809, p<0.01) associated with dialysis withdrawal proposal in four scenario (scenario 1,2,3,5). Age factor also affected dialysis withdrawal decision-making (odds ratio: 2.294, 2.085, 3.200, 1.862, p<0.01) in four scenario( scenario 1-4). The significance of associated factors in dialysis withdrawal was modified in different extents after adjusted with demographic background. It represents that the decision-making in dialysis withdrawal is a dynamic process, which is influenced by physician’s personal characteristics.
Conclusion: Physicians exert different thinking process according to different clinical scenarios. Our study identified factors associated with dialysis withdrawal decision-making process. Further education program will be indicated for junior doctors about timing and consideration in dialysis withdrawal to achieve optimal end-of-life care in critically-ill ESRD patietns.

並列關鍵字

dialysis withdrawal ； End-stage renal disease (ESRD) ； Critically-ill ； decision-making ； end-of-life care

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