探討影音決策輔助工具運用於老年重症病患之醫療決策代理人的醫療決策意向與決策品質之成效

背景：加護病房疾病嚴重度與死亡率高，需要複雜的醫療決策，而死亡多以老年重症居多，家屬在面臨替代重症病患進行攸關生死的醫療處置時，常處於選擇積極的維持生命治療或接受緩和醫療照護間決策之困境。台灣的社會民情趨於保守，老年重症病患之家屬面臨醫療決策之際，強大的負面壓力常有拒絕面對、失落感甚至醫療決策衝突。目的：本研究旨在探討運用影音決策輔助工具於加護病房老年重症病患醫療決策代理人之醫療決策意向與醫療決策品質的成效。方法：本研究採臨床隨機分派研究設計(Randomized Clinical Trial)，以中台灣某區域教學醫院內外科加護病房之老年重症病患醫療決策代理人為研究對象，隨機分派以抽籤決定單月份為控制組，雙月份為實驗組。透過自行發展的醫療決策影音輔助工具，使用結構式問卷探討對醫療決策代理人的醫療決策意向與決策品質的影響；兩組醫療代理決策者完成基本資料與醫療決策意向問卷（前測）後進行常規醫病討論會，實驗組於醫病討論會後予介入影音決策輔助工具，72小時後，兩組再完成醫療決策意向問卷（後測）與醫療決策品質問卷。研究資料採用SPSS 22.0版進行卡方檢定、獨立樣本t檢定及配對t檢定檢測分析驗證假設。結果：本研究納入老年重症病患之決策代理人共74位，實驗組37位，控制組37位，研究分析顯示實驗組在介入影音決策輔助工具後，在醫療決策意向（後測）之維持生命治療層面與緩和醫療層面相較於控制組，平均分數顯著高於控制組(p < 0.05)；兩組在醫療決策意向前後測差分析顯示實驗組於影音決策輔助工具後之醫療決策意向顯著高於控制組(p < 0.05)；而在醫療決策品質分析顯示，實驗組顯著優於控制組(p < 0.05)。結論：影音決策輔助工具不僅可以提供決策代理人了解重症病患醫療處置的益處與風險外，並能促進醫病溝通與醫療決策時的思考方向。

關鍵字

影音決策輔助工具；老年重症；決策代理；醫療決策行為意向；決策品質

並列摘要

BACKGROUND: The family or surrogates face the dilemma of substitute for critically ill patients’ medical decision with lifesaving or palliative treatments. Since traditional conservative culture in Taiwan, while family members of seriously patients face medical decision-making, the heavy burden often results in decision conflicts, refusal, and upset. OBJECTIVE: The purpose of this study was to exploring the effectiveness of video decision aids applied for elderly critically ill patients’ medical surrogate on their medical decision-making intention and decision-making quality. METHODS: A randomized clinical trial design was conducted in a regional teaching hospital in central Taiwan to test hypotheses. The participants were surrogate decision-maker of the elderly patients in the surgical or internal medicine intensive care unit. Participants of the experimental group were provided a video decision aids, whereas the control group received a general routine, and to evaluate the impact of medical intention and medical decision quality of surrogate decision-maker by structured questionnaire:『Behavioral Intention scale of Medical Decisions in the Critical Illness Patients Surrogate』 and 『SURE test』. The Chi-square test, independent sample t-test and paired t-test were performed using SPSS version 22.0 and by analysis. RESULTS: This study included 74 surrogate decision-maker for elderly critically ill patients, 37 in the experimental group, and 37 in the control group. The research revealed that the experimental group followed the intervene video decision-making aid, compared with the control group, the life-sustaining treatments dimension and the palliative treatments dimension of the medical decision-making intentions are significantly different (p <0.05); The posttest analysis of two groups with medical decision-making intention, which revealed that experimental group’s after the video decision-making aid reached statistically significant trend to palliative treatment care (p <0.05); The experimental group had a significant improvement on the quality of medical decision-making after received video decision-making aid. CONCLUSION: Video decision-making aids not only provide surrogate decision-maker to understand the benefits and risks of medical treatment of critically ill patients, but also promote communication and decision-making of thinking.