建立癌症病人預立醫療指示的行為準備度之預測模式

Developing a model to predict the cancer patients' readiness to execute advance directives

楊嘉玲(Chia-Ling Yang)

指導教授 ： 胡文郁

國立臺灣大學/醫學院/護理學研究所/博士(2012年)

https://doi.org/10.6342/NTU.2012.02407

摘要

背景與目的
癌症病人進展至疾病晚期時，有很高的機會突然面臨死亡，因此必須要能儘早針對生命末期醫療方式進行討論。預立醫療照護計畫的介入，進而協助病人完成預立醫療指示是末期醫療照護的核心理念。然而，癌症病人參與預立醫療照護計畫進而預立醫療指示的比例仍相當低，且對於其影響機制仍缺乏完整的概念架構及預測模式。故本研究目的為，確立癌症病人預立醫療指示的行為準備度之預測模式，以作為預立醫療照護計畫介入之依據。

方法
本研究採前瞻性、橫斷式調查研究設計。以北部某醫學中心的腫瘤及血液腫瘤科病房，年滿二十歲之住院癌症病人為對象，採結構式問卷面對面訪談或自填方式收集資料。主要測量項目包括，預立醫療指示知識、預立醫療指示決策權衡、重要他人影響度、決策自我效能、醫療決策自主偏好、維生處置偏好等自變項，以及依變項預立醫療指示行為。所收集之資料以SPSS 16.0版及Amos 7.0版套裝軟體進行統計分析，以描述性統計呈現研究對象屬性及各變項分布情形，再以單因子變異數分析、雙變項相關分析與回歸分析找出主要影響變項，進而使用路徑分析建構癌症病人預立醫療指示的行為準備度之預測模式。

結果
本研究211位研究對象平均年齡為47.29歲（SD= 13.69），以男性、已婚、教育程度高中職(含)以上、信仰佛道教者居多; 罹患固態惡性腫瘤者占六成(60.2%)，目前癌症階段屬於控制期者居多(56.7%)，曾接受過的癌症治療方式以化學治療者最多171人次(82.6%)，KPS 90分者(76.8%)或ECOG 1分(79.3%)者占大多數。主要研究結果為，1) 僅約近三成四的癌症病人曾與他人討論過自己的末期醫療偏好;「預立醫療指示」行為準備度，以處於「意圖期」者居多(52.6%)，僅2.8%癌症病人已預立醫療指示。2) 路徑分析結果顯示，預立醫療指示決策權衡、重要他人影響度、醫療決策自主--末期病情告知、偏好接受急救措施--無藥可治、ECOG等因素為預立醫療指示的行為準備度之直接預測因子，修正後總解釋量為30%。3) 預立醫療指示決策權衡為預立醫療指示知識、決策自我效能對預立醫療指示行為準備度之中介變項。

結論與建議
本研究以跨理論模式蒐集到之實證結果顯示，癌症病人在末期醫療決策上多期待能與醫療專業人員、家人共同討論。醫療專業人員應要評估病人對於預立醫療指示的意願，主動提供相關的訊息，並有系統的討論與介入，以提升預立醫療指示簽署率。在教育及政策面上可從，預立醫療指示決策權衡、預立醫療指示重要他人影響、醫療決策自主偏好--告知末期病情、接受急救措施的偏好等重要因素進行介入性措施。此外，提升癌症病人對於預立醫療指示的認知，以及增進個人在醫療決策時的自我效能，將有助於強化癌症病人對於預立醫療指示正向的感受
，進而增加其對於預立醫療指示行為準備度。本預測模式可作為設計預立醫療照護計畫介入措施之參考依據，以提升癌症病人預立醫療指示的行為準備度。未來建議納入更多元的研究群體，進行縱貫性研究，以增加樣本代表性及結果的推論性。

關鍵字

癌症病人 ； 預立醫療指示 ； 準備度 ； 決策權衡 ； 維生處置

並列摘要

Background and Objective
Cancer patients face a substantial risk of death as their disease progresses into the terminal phase. Because of this condition, doctors should discuss end-of-life treatments with patients as early as possible. The essential concept of end-of-life treatment involves intervention through advance care planning to help patients in executing advance directives. However, only low proportion of patients is usually willing to participate in such planning and execution procedures. Moreover, patients often lack a comprehensive understanding of the framework and prediction model of such a mechanism. This study aimed to construct a model for predicting cancer patients’ readiness to execute advance directives, which can serve as a basis for intervention measures of advance medical care planning.

Methods
This study adopted a prospective, cross-sectional design. Hospitalized cancer patients aged 20 and older were chosen from a medical center in Northern Taiwan as study participants, and the structured questionnaires were applied to collect data through face-to-face interviews or questionnaire self-administration. The primary measurement tools included independent variables such as knowledge about advance directives, decision balance tower advance directives, influence of significant others on advance directives, decision self-efficacy, preference of medical decision, preference of life-sustaining treatment, and stage of change regarding advance directives. The collected data were statistically analyzed using SPSS 16.0 and Amos 7.0 software suites, and the participant properties and distribution of variables were derived by performing descriptive analysis. One-way ANOVA, bivariate correlation analysis, and regression analysis were then applied to determine the primary influential factors. Thereafter, path analysis was applied to construct a model for predicting cancer patients’ readiness to execute advance directives.

Results
A total of 211 participants, whose average age was 47.29 (SD = 13.69), participated in this study. The majority of participants were male, married, with a high school education or higher, and Buddhists. A total of 60.2% of the participants had solid malignant tumors, and most participants were in the control periods of their disease (56.7%). A total of 171 participants (82.6%) had received chemotherapy, 76.8% of the participants had the Kamofsky performance status (KPS) score of 90, and 79.3% of the participants had the Eastern Cooperative Oncology Group (ECOG) performance status score of 1. The primary results of this study were as follows: (1) Approximately 34% of the cancer patients had discussed their preferences of terminal phase treatment with others. Most of the patients were still in the contemplation stage (52.6%) regarding their readiness to execute the advance medical directives. Only 2.8% of the patients had already established advance medical directives. (2) Path analysis results indicated that factors such as decision balance power of advance directives, influence of significant others on advance directives, medical decision self-efficacy, terminal condition information, preference of life-sustaining treatment, no treatment available, and ECOG were direct predictive factors of readiness in executing advance medical directives. The total explanatory power was 30% after revision. (3) The decision balance power of advance directives was the intervening variable for the advance directive behavior readiness in knowledge about advance directives and decision self-efficacy.

Conclusion and Suggestions
This study collected empirical results by applying a transtheoretical model, and the results indicated that the cancer patients generally anticipated discussing terminal treatment decisions with medical professionals and family members. Medical professionals should therefore evaluate patients’ intentions regarding advance medical directives. By proactively providing patients with relevant information, and by introducing discussion and intervention systematically, the signing rate of advance directives can be further enhanced. Concerning educational and governmental policies, intervention measures can be performed by providing relevant information for decision balance power of advance directives, influence of significant others on advance directives, decision self-efficacy, terminal condition, and preference of life-sustaining treatment. In addition, strengthening cancer patients’ knowledge regarding advance medical directives and improving the decision self-efficacy of individual patients regarding medical decisions can facilitate patients’ positive feelings about advance directives. This in turn improves the patients’ readiness in executing such directives. Consequently, this prediction model can serve as reference for establishing medical caring intervention measures, focusing especially on promoting the cancer patients’ readiness in executing advance directives. For future studies, it is recommended that an extensive range of study participants are included, and that a longitudinal study is conducted to increase sample representativeness and result inference.

並列關鍵字

cancer patient ； advance directives ； readiness ； decision balance ； life-sustaining treatment

參考文獻

張慧玉(2009)．探討終末病患照護中有關預立醫囑、生前預囑之現況及倫理法律問題．(未發表碩士論文) ．臺北醫學大學護理學研究所，台北市。

鈕則誠. (2004)．生命教育-倫理與科學．台北: 揚智出版社。

楊秀儀(2004)．救到死為止？--從國際間安樂死爭議之發展評析臺灣「安寧緩和醫療條例」．國立臺灣大學法學論叢，33(3)，1-43。

張惠雯、顏啟華、林鵬展 & 劉立凡 (2011)．病人對預立醫囑的看法－以彰化某醫院家庭醫學科門診病人為例．安寧療護雜誌，16(3)，296 -311。

孫效智(2012)．安寧緩和醫療條例中的末期病患與病人自主權．政治與社會哲學評論, 41。