醫護人員對預立醫療指示之知識、態度、行為意向及其相關因素探討

The relationship between knowledge, attitude, and behavioral intentions of advance directives among medical staff

陳嘉琪(Chia-Chi Chen)

指導教授 ： 吳佩玲

共同指導教授 ： 白香菊(Hsiang-Chu Pai)

中山醫學大學/醫學院/護理學系/碩士(2021年)

https://doi.org/10.6834/csmu202100219

摘要

背景：台灣於2000年通過的安寧緩和醫療條例，以尊重末期病人醫療自主權為首要考量，法案第五條明定具行為能力之成人得預立醫療，讓簽署者依自己的意願接受醫療照顧方式直到死亡，在生命的末期保有控制權與自主權。身為第一線與病患及家屬面對面的醫護人員，當病患或家屬提出預立醫療指示相關議題時，身為醫護照顧提供者，是否已準備好回答相關問題呢？
目的：本研究旨在了解醫護人員對於預立醫療指示之知識、態度及簽署預立醫療指示的行為意向。
方法：採橫斷式研究（cross-sectional study）設計，方便取樣，使用結構式問卷進行預立醫療指示的知識、態度和行為意向的調查，於中部某區域教學醫院共納入298名醫師及護理人員（醫師31人、護理人員267人）；以描述性及推論性統計分析醫護人員對預立醫療指示的知識、態度及行為意向，並以Pearson Correlation分析基本屬性與知識、態度及行為意向的相關性，多元及逐步迴歸分析探討影響預立醫療指示行為意向的預測因子。
結果：研究顯示，基本屬性中｢性別｣（p =0.047）、｢婚姻狀況｣（p =0.029）在預立醫療指示知識具差異性，進行事後檢定發現，女性、未婚者在知識方面比男性、已婚者好；而預立醫療指示的態度方面則以｢年齡｣（p = 0.007）、｢婚姻狀況｣（p = 0.021）、｢工作年資｣（p = 0.042）具差異性，進一步進行事後檢定分析，結果發現年齡較輕、工作年資較淺、未婚者在預立醫療指示態度方面更積極正面；而行為意向與基本屬性並無顯著差異。
在預立醫療指示知識方面，總分為14-28分（M =21.691,SD =2.072），得分越｢高｣表示對預立醫療指示知識越清楚，知識了解程度越｢好｣；在態度方面，總得分為11~44分（M = 36.6,SD = 6.85），總分越高則表示態度越正向；在行為意向方面總得分為9~20分（M =16.7,SD = 2.39），當分數越高則簽署並註記於健保IC卡的意願越高，簽署及健保IC卡註記之行為意向方面，有意願簽屬者佔36.6%，但實際完成預立醫療指示並將其註記於健保卡比率僅3.3%（10人）。
再以Pearson Correlation驗證基本屬性與預立醫療指示的知識、態度及願意簽署預立醫療指示的原因發現，年齡與態度（r= -0.165, p = 0.004）及年資與態度（r =-.141, p=.015）為負相關，態度與行為意向（r = 0.383, p= 0.000）為中等相關，另外，在迴歸模式中整體的預測變數對於依變數的有效解釋變異量為21.7%。逐步回歸分析結果得知態度為解釋力為14.4%（F = 50.976; p = 0.000）為最強預測因子，另外可選擇自己對臨終醫療處置與照護之意願的保障解釋力為5.1%（F = 37.026; p = 0.000；R2 = 0.054）、可無遺憾安詳且有尊嚴的死亡解釋力為1.7%（F= 27.620; p = 0.000）。
結論與建議：從本研究得知態度、可選擇自己對臨終醫療處置與照護之意願的保障和可無遺憾安詳且有尊嚴的死亡為醫護人員預立醫療指示行為意向之預測因素；其中又以態度為簽署行為意向的最強預測因子。當醫療指示的態度越正向則簽署預立行為意向越高；而｢可無遺憾安詳且有尊嚴的死亡｣、｢可選擇自己對臨終醫療處置與照護之意願的保障｣，增加了簽署預立醫療指示的意願。
研究顯示醫護人員雖在預立醫療指示的知識普遍不足，且大多數醫護人員對預立醫療指示簽署仍存在著不確定感，即便是有意願簽署，但實際簽署比例仍偏低；建議在考慮在職教育時必須以學習者為主，了解醫護人員的學習需求與限制，針對不同階段與臨床資歷安排學習內容，並規劃多元的學習型態，以滿足不同資歷需求。另外，在註記醫療意願於健保IC卡方面，建議簡化流程，或透過簡易流程圖的教學增加大眾簽署意願。

關鍵字

醫護人員 ； 預立醫療指示 ； 知識 ； 態度 ； 行為意向

並列摘要

Background: The Hospice-Palliative Care Act, enacted in Taiwan in 2000, respect for the medical autonomy of terminal patients. Article 5 of the Act states that adults with legal capacity may have Advanced Directive, and let the signer receive medical care as he wishes until death, retain control and autonomy at the end of life. As a medical staff should be ready for the issue , when patients or family members raise questions related to Advanced Directive.
Objective: The purpose of this study was to explore the knowledge, attitudes and behavior intention of advance directive among medical staff.
Method: Cross-sectional designs and convenience sampling were used. The questionnaires comprised the three scales of knowledge, attitudes and behavior intention of advance directive. There were 298 participants (31 doctors and 267 nurses) whom were recruited from regional teaching hospital in central Taiwan. Data were analyzed by using descriptive statistics, t-test, one-way ANOVA, and Pearson correlation to analyze the relationship between participants’ characteristic, knowledge, attitude and behavioral intention; multiple and stepwise regression analysis was used to explore the predictors of behavioral intention of advance directive.
Results: Results: In the knowledge of advance directive, there were differences among sexual （p = 0.047）and Marital status（p = 0.029）, age（p = 0.007）, seniority (p =0. 021) and Marital status (p = 0.015) were significantly different in the attitude of advance directive, and younger (p = 0.017, F = 2. 639), shorter accumulated years of work (p = 0. 021, F = 3. 931) and unmarried (p = 0.015, F = 2) were more positive; There is no basic data difference in the behavioral intention of advance directive. In terms of the knowledge of advance directive, the total score was 14-28 points (M =16.7, SD = 2.39). The higher the score, the better the knowledge. In terms of attitude, the total score was 11-44 (M = 36.6, SD = 6.85). The higher the total score, the more positive the attitude. The total score of behavioral intention was 9-20 (M = 16.7, SD = 2.39). The higher the score, the higher the willingness to sign and note the IC card.36.6% of the respondents were willing to mark advance directive in National Health Insurance (NHI) identification card (IC). However, only 3.3% of the respondents (n =10) actually completed the advance directive and marked them on the IC. Pearson correlation was used to verify the knowledge and attitude of basic attributes, and the reasons for signing advance directive. There is a negative correlation between age and attitude (r = -0.165, p = 0.004), seniority and attitude (r = -0.141, p = 0.015). Attitude and behavior intention (r = 0.383, p = 0.000) are moderately correlated. The overall multiple regression analysis model reached a significant level (F = 6.489; p = 0.000; R2 = 0.257; adjusted R2 = 21.7). In the regression model, the effective explanatory variance of the overall predictive variable for the dependent variable was 21.7%.
The result of stepwise regression analysis shows that the attitude was (explanatory power 14.4%, F = 50.976; p = 0.000) is the strongest predictor. The explanatory power of choosing one's own will for end-of-life medical treatment and care is 5.1% (F = 37.026; p = 0.000; R2 = 0.054), the explanatory power of peaceful and dignified death without regrets is 1.7% (F = 27.620; p = 0.000).
Conclusions and recommendations: From this study, we know that attitudes, the protection of their willingness to choose their own dying medical treatment and care, and the possibility of a peaceful and dignified death without regrets are the predictive factors of medical staff's intention to make advance directive. Among them, attitude is the strongest predictor. The research shows that the knowledge of the medical staff is generally insufficient, and most of the medical staff are still uncertain about the signing of the advance directive. Even the willingness to sign advance directives is high, the actual signing ratio is still low.we should ,understand the learning needs and limitations of medical staff, and arrange learning contents according to different stages and clinical qualifications,In addition, it is suggested to simplify the process to increase the public's willingness to mark the advance directives in the IC .

並列關鍵字

Medical staff ； advance directive ； knowledge ； attitude ； behavior intention

參考文獻

中文參考資料

王紅英（2014）。探討醫護人員對不施行心肺復甦術的認知及態度（未出版之碩士論文）。中台醫護科技大學，台中市。

中華民國護理師護士公會全國聯合會（2021）．202103_台閩地區護理人員統計表。https://www.nurse.org.tw/publicUI/H/H102.aspx

行政院性別平等會（2021）．109年重要性別統計資料庫．https://www.gender.ey.gov.tw/gecdb/Stat_Statistics_Field.aspx

辛幸珍（2006）．以家庭為中心之價值觀對老年末期醫療抉擇之影響－比較台灣年老者與紐西蘭老人之觀點．台灣醫學人文學刊，7（1、2），179-190。https://doi.org/10.30097/FJMH.200606.0012