慢性阻塞性肺病病人接受生命末期維生處置之行為意向與其影響因素

研究背景與目的慢性阻塞性肺病（Chronic Obstructive Pulmonary Disease，COPD）的罹病率及死亡率在全世界有增加的趨勢，其病程進展的特性，使其發生非預期性的死亡威脅增加，突然面臨需要做維生處置決策的機會很高。已有研究顯示其於生命末期接受侵襲性及加護性醫療處置，甚至最後死於加護病房或醫院的比例均明顯偏高，影響病人本身生命最後階段的生活品質與死亡品質;這樣的情況可能不是病人本身想要的結果。因此瞭解病人對於生命末期接受維生處置的意向顯得格外重要。因此本研究目的期能藉由探討慢性阻塞性肺疾病人對於生命末期接受維生處置的意向及其影響因素，而能提供更適切的末期照護。研究方法本研究採橫斷性調查研究法，以立意取樣方式於北區二家醫學中心胸腔呼吸科病房及門診進行收案，研究對象為COPD病人，選樣標準為:確立診斷為COPD，第二期至第四期病人（依GOLD 分期標準）：意識清楚具有溝通能力；願意參與研究並簽署同意書者。以結構性問卷，面對面訪談方式收集資料，主要測量工具有「維生處置意向量表」、「生命末期照護知識量表」、「維生處置態度量表」、和「善終概念量表」。將所得資料，以SPSS 18.0版本套裝軟體進行描述性統計、獨立樣本T檢定、單因子變異數分析、皮爾森相關分析與多元線性迴歸分析。結果本研究有110位COPD病人為有效樣本，平均年齡71歲(±10.0），男性居多(81.8%)、多數為已婚、教育程度國小以下，近四分之一(23.9%)居家用氧。多數病人(71位，65%)認為維生處置應由自己決定，八成(84%)病人希望生命末期能以舒適性照顧為主。整體而言，病人對於生命末期接受維生處置意向程度偏低，意向強度隨所處情境、維生處置項目的不同而有差異。在五個不同情境，接受「維生處置意向」由高而低依序為：在目前的健康狀況下(平均分數2.92，1-5分)、呼吸困難極度嚴重時(2.62)、須靠呼吸器維持維生(1.56)、無效醫療(1.44)、呈植物人狀態意向最低(1.26)。在十二項不同維生處置中，接受的意向依序為：使用抗生素、注射升壓藥物、注射急救藥物、非侵襲性面罩呼吸器、人工呼吸術、體外心臟按摩、鼻胃管灌食、心臟電擊、洗腎、氣管內插管、氣管切開術最低。對病情的瞭解程度差、自覺肺部嚴重度為中度、對維生處置抱持正面態度及認為善終較不重要者，是COPD病人「接受維生處置意向」的重要影響因子，共可解釋32.1%的變異量。結論目前國人預立醫療指示還不普及，臨床上COPD病人生命末期的維生治療處置決策，大多由家屬在危急情況下代做決策，然而研究發現大部分COPD 病人希望由自己決定；2019年我國「病人自主權利法」即將上路，應將COPD病人列入預立醫療照顧諮商(advance care planning)的優先對象，因COPD晚期病人急性惡化而需面臨維生處置抉擇的機會非常高。對於病情的瞭解度、自覺肺病疾病的嚴重度與維生處置的態度，有賴於醫療專業人員病情告知提供足夠且正確的訊息並適當的溝通，對病人而言，這些重要訊息會影響其接受維生處置的意向。認為善終重要的病人，接受維生處置的意向低，發展更完善且符合COPD病人末期照護的模式刻不容緩。專業人員應促進病人、家屬與專業人員間，儘早展開維生處置議題的溝通，並提供充分的訊息，透過充分持續地討論與澄清，破除病人對於維生處置態度上的迷思，以協助做出真正符合其意向的決策，提供更符合COPD病人生命末期需求之照護；也可做為推動「預立指示」政策上的參考。

關鍵字

慢性阻塞性肺病；維生醫療處置；生命末期；行為意向；決策

並列摘要

Abstract Background and purpose The mortality and morbidity rates of Chronic Obstructive Pulmonary Disease (COPD) are increasing worldwide. There is evidence of COPD patients receiving more invasive and intensive medical care at the end-of life (EoL) and the number of those who die in intensive care units or hospitals is significantly higher than that of patients with other diseases. The trajectory characteristics of COPD which interludes of acute exacerbation make the disease dramatic decline. The incidence of unexpected threats to life has increased and patients are increasingly facing the need to make decisions about life-sustaining treatments (LSTs) that they never considered previously. Decisions for receiving LSTs at EoL not only influence patients’ quality of life at their final stage of life, but also substantially affect their quality of dying. These results may not reflect the want of COPD patients. Thus, it is necessary to understand the intentions of COPD patients regarding LSTs at EoL.This study aimed to explore the intentions of the COPD patients to receive LSTs at EoL and its related factors, which could be helpful in providing more appropriate care to them. Methods This study adopted a cross-sectional design and used purposive sampling. It was reviewed and approved by the hospital institutional review board. Participants were recruited from two hospitals at northern Taiwan. The inclusion criteria for patients were as follows: COPD patients in stage II to IV (according to the staging criteria of the Global Initiative for Chronic Obstructive Lung Disease), conscious and able to communicate, and willing to participate in the study. Data were collected through a structured questionnaires and face-to-face interviews. The contents of questionnaires included: (1) demographic data: including gender, age, education level of education, marital status, religion, and EOL care preferences, etc.; (2) scale of intention to receive LSTs; (3) COPD Assessment Tool; (4) knowledge about EoL care; (5) attitude toward LSTs; and (6) concept of good death. Statistical analyses were performed using SPSS version 20.0 for Windows. The descriptive statistics were computed for each dependent and independent variable. Pearson’s correlation coefficients were applied to test interrelationships among study variables and for multicollinearity. Variables that were significantly correlated to the scores of the intention to receive LSTs were entered into multiple regression to determine those that predicted the level of intention to receive LSTs at EoL. The two-tailed p- value of .05 was adopted as the significance standard. Results A total of 110 valid samples were obtained. The average age of COPD patients was 71 (±10.0) years, and most were married males with primary school education or lower. Almost a quarter (23.9%) was using home oxygen treatment. When the disease became terminal, most patients and families wanted a physician to inform them about it. Most patients preferred comfort care over receiving every treatment to prolong life. More than half believed that the decisions about LSTs should be made by themselves. However, almost half (45%) reported that their family members were unaware of their intentions about LSTs. Most patients did not specify a proxy.The level of willingness toward receiving LSTs of patients varied according to their situations and LST interventions. The situation factors that played a role in intentions to receive LSTs, in the descending order, were: current status, severe dyspnea greatly influencing the self-care activity, ventilator-dependence for survival, medical futility, and vegetative state. When the outcome is poor, that is, in case of medical futility or vegetative state, the intention to receive LSTs greatly reduced. Among the different LST interventions, the intentionof patients to use antibiotics was the highest, followed by injection of vasopressors and Noninvasive ventilation.. The LSTs with the lowest patient intention, in the descending order, were: tube feeding, hemodialysis, and tracheostomy. Overall, the degree of patients’ intentions to receive LSTs depended on the invasiveness and burden of the LSTs.Patients who had poor understanding of their disease, perceived moderate severity of disease, had a more positive attitude towards LSTs, and perceived the good death to be less important had more intentions to receive LSTs at EoL. These four variables explained 32.1% of total variance. Conclusions Currently, the utilization of advance directives (ADs) is still not widespread among COPD patients. COPD patients wanted make their own decisions regarding LSTs. Most did not wish to receive LSTs that potentially prolong the dying process. Clinicians should promote communication and provide an opportunity for patients to actively participate in the decision-making for their EoL care. Possible outcome and detail information about LSTs should be included in the discussion of EoL care. Adequate information on COPD patients’ condition and possible LSTs should be provided. Auxiliary media should be developed in the future to assist patients in understanding LSTs for preparing to discuss advance care planning. With adequate and continuous discussion to reveal patients' intentions to receive LSTs, a mutual shared decision can reduce the chances of COPD patients receiving inappropriate LSTs.

並列關鍵字

Chronic Obstructive Pulmonary Disease ； life-sustaining treatment ； end of life ； intention ； decision- making

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慢性阻塞性肺病病人接受生命末期維生處置之行為意向與其影響因素

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