臺灣博碩士論文加值系統

研究背景與目的：
癌症為國內外十八歲以下兒童主要死亡原因之一，過去研究顯示癌症病童於死亡前經歷了較多以治癒為目的過度醫療，而安寧緩和療護的使用率則較低。本研究旨在了解1.癌症病童生命末期醫療照護現況；2.安寧緩和療護的使用情形；並進一步探討3.癌症病童人口學與疾病特性、安寧緩和療護使用情形與其生命末期照護情形的相關性。
研究方法：
採回溯性病歷回顧，收集癌症病童生命末期醫療照護相關資料，研究對象為2010年1月至2012年12月間，於台北市某醫學中心兒童血液腫瘤科治療並於此醫學中心死亡之癌症病童，其初診斷年齡小於18歲，死亡年齡可能大於18歲。共有67名研究樣本。
研究工具：
採用自擬之記錄表格，內容共八大項，分別為：病童及家庭基本資料、疾病資料、最後一次住院及死亡相關資料、生命最後一個月醫療照護、死亡前24小時醫療資源使用情形、CPR情形、DNR簽署情形，及安寧緩和療護使用情形。資料經整理編碼後，使用SPSS 18.0統計軟體進行統計分析。
研究結果：
67位研究樣本中，男童佔56.7%（40位），家中獨生子女佔16.4%（11位），診斷為白血病/淋巴癌佔56.7%（38位）。平均診斷年齡為8.50±5.23歲，平均死亡年齡為11.75±5.70歲。
癌症病童在生命末期階段經歷了長時間的住院治療並接受了許多過度醫療。91%（61位）的研究樣本在死亡前三十天內住院天數大於14天，43.3%（29位）的癌症病童在死亡前三十天內有住入加護病房的紀錄，34.3%（23位）於加護病房過世。16.4%（11位）的癌症病童在死亡前三十天內曾接受新的化學治療，34.3%（23位）在死亡前十四天內有接受化學治療。34.3%（23位）在死亡前24小時內有使用氣管內插管及呼吸器，35.8%（24位）有使用強心劑，13.4%（9位）在死亡前三天內曾接受心肺復甦術。
與過去研究相比，癌症病童使用安寧緩和療護的比例有提升，但照會時機仍較晚。本研究所有樣本的安寧照會率為56.7%、安寧涵蓋率為40.3%，照會日期的中位數為死亡前 36.5天，21%在死亡前七天內初次照會。在DNR簽署方面，94%（63位）的研究樣本在死亡前有簽署DNR同意書/意願書的紀錄，但簽屬時機較晚。簽署日期至死亡日期中位數為4.5天，18.3%（11位）在死亡當天才簽，33.3%（21位）在簽署時已插氣管內管。
死亡年齡大於12歲且診斷為白血病/淋巴癌的癌症病童，在末期照護上與其他樣本有較大差異。這組樣本於加護病房死亡的比例顯著較高（p<0.05），死亡前24小時內接受氣管內插管、使用抗生素和強心劑的比例顯著較高（p<0.05），而DNR的簽署時間則較晚，簽署前已接受氣管內插管的比例顯著較高（p<0.01）。
安寧緩和療護的使用情形與生命末期照護有相關性。死亡前曾接受安寧共同照護者，在簽署DNR的時間顯著較早（p<0.01），於加護病房死亡的比例顯著較低（p<0.01），死亡前24小時內接受氣管內插管和強心劑的比例顯著較低（p<0.01），使用鴉片類止痛藥物的比例顯著較高（p<0.01）。
討論與臨床應用：
安寧緩和療護使用情形與癌症病童生命末期照護情形有相關性。臨床醫護人員若能在適當時機照會安寧共同照護團隊，及早與癌症病童及家屬討論臨終醫療決策，能降低癌症病童在生命末期接受過度醫療使用的情形。

Background and Purposes:
Childhood cancer is one of leading causes of death in children and adolescents. Cancer children received aggressive treatments near the end of life. This study aimed to explore the end-of-life care and the use of palliative care among cancer children in Taiwan, and to explore the correlation between the characteristics of cancer children, the use of palliative care and the end-of-life care.

Methods:
A retrospective chart review was conducted. All subjects were diagnosed of cancer under 18, and died between January 2010 to December 2012 in a medical center in Taipei. The total valid sample size was 67.

Measurement:
The data were collected by a self-developed structured form, which included: (1) patient and family characteristics, (2) oncology summary, (3) information of last hospitalization, (4) aggressiveness of cancer care near the end of life, (5) medical use in the last 24 hours of life, (6) CPR status, (7) DNR status, and (8) the use of palliative care. The data were analyzed by the Software SPSS 18.0.

Results:
In 67 study subjects, 56.7% were male, 16.4% were single child, 56.7% were diagnosed of leukemia/lymphoma. The average age of diagnosis was 8.50±5.23, and the average age of death was 11.75±5.70.
Cancer children experienced long-term hospitalization and aggressive treatments near the end of life. 91% were hospitalized more than 14 days in the last 30 days of life. 43.3% were admitted to ICU in the last 30 days of life, and 34.3% were died in ICU. 16.4% received new chemotherapy in the last 30 days of life, and 34.3% received chemotherapy within 14 days before death. 35.8% received inotropic agents in the last 24 hours of life, and 13.4% received cardiac pulmonary resuscitation within 3 days before death.
Although the use of palliative care is increasing, the referral timing was still late. In all subjects, 56.7% received hospice consultation before death, and 40.3% received hospice shared care. The average days of first hospice consultation to death was 50.61±54.83 days (median: 36.5 days), and 21% received first hospice consultation within 7 days before death. DNR permits completed 27.85±56.8 days prior to death (median:4.5 days), and 18.3% completed at the same day of death.
Patients who were diagnosed of leukemia/lymphoma and died at the age above 12, are more likely to receive aggressive treatments near the end-of-life than other subjects. They were more likely to die in ICU (p<0.05), and were more likely to use ventilators, antibiotics and inotropic agents within the last 24hours of life.
Relationship exists between the usage of palliative care and the end-of-life care of cancer children. Patients who had received hospice shared care were less likely to die in the ICU (p<0.01), and had a lower rate of the use of ventilator and inotropic agents within the last 24 hours of life (p<0.01). The DNR orders were completed earlier in the patients received hospice shared care (p<0.01).

Conclusions and Nursing Applications:
Relationship exists between the usage of palliative care and the end-of-life care of cancer children. Clinical health providers should consult hospice/palliative care team and conduct palliative discussion with patients and family at a proper time, to improve the end-of-life care for cancer children.

致謝 …………………………………………………………………………………i
中文摘要 …………………………………………………………………………… ii
英文摘要 ………………………………………………………………………… iv
第一章 緒論 ………………………………………………………………………1
第一節 研究背景及重要性 …………………………………………………1
第二節 研究目的 ……………………………………………………………3
第三節 研究假設 ……………………………………………………………4
第四節 名詞界定 ……………………………………………………………5
第二章 文獻查證 …………………………………………………………………7
第一節 安寧緩和療護的發展 ………………………………………………7
第二節 兒童安寧緩和療護的發展 …………………………………………9
第三節 癌症病童末期照護現況及需求……………………………………14
第四節 兒童安寧緩和療護與生命末期研究趨勢…………………………18
第三章 研究方法 …………………………………………………………………20
第一節 研究架構……………………………………………………………20
第二節 研究設計……………………………………………………………21
第三節 研究場所與對象……………………………………………………22
第四節 資料收集過程………………………………………………………23
第五節 研究工具……………………………………………………………25
第六節 資料分析……………………………………………………………31
第七節 倫理考量……………………………………………………………32
第四章 研究結果 …………………………………………………………………33
第一節 研究對象之人口學及疾病屬性……………………………………34
第二節 癌症病童死亡前醫療照護情形……………………………………38
第三節 DNR簽署及安寧緩和療護使用情形 ……………………………45
第四節 人口學特性與末期照護之相關性…………………………………49
第五節 安寧緩和療護與末期照護之相關性………………………………87
第五章 討論 ………………………………………………………………………98
第一節 癌症病童生命末期醫療照護現況…………………………………98
第二節 癌症病童簽署DNR及安寧緩和療護使用現況…………………101
第三節 癌症病童人口學及疾病屬性與末期照護的相關性 ……………103
第四節 安寧緩和療護與末期照護之相關性 ……………………………105
第六章 結論與建議………………………………………………………………106
第一節 研究結論 …………………………………………………………106
第二節 護理上的應用 ……………………………………………………108
第三節 研究限制與建議 …………………………………………………109
參考文獻……………………………………………………………………………110
中文部分 ………………………………………………………………………110
英文部分 ………………………………………………………………………112
附錄一 癌症病童末期醫療資料收集表 …………………………………………118
附錄二 不施行心肺復甦術同意書/意願書 ………………………………………121
附錄三 台灣大學醫學院附設醫院研究倫理委員會核准公文 …………………124



表目錄
表1. 癌症病童生命末期相關研究 …………………………………………………17
表4.1.1 研究樣本人口學及疾病屬性 ……………………………………………36
表4.1.2 研究樣本癌症診斷類別……………………………………………………37
表4.2.1 死亡前最後一次住院情形…………………………………………………39
表4.2.2 癌症病童死亡地點…………………………………………………………39
表4.2.3 死亡前三十天住院情形……………………………………………………42
表4.2.4 死亡前住院及化療情形……………………………………………………43
表4.2.5 癌症末期過度醫療指標……………………………………………………43
表4.2.6 臨終醫療處置情形…………………………………………………………44
表4.3.1 DNR簽署情形………………………………………………………………47
表4.3.2 安寧緩和療護使用情形……………………………………………………48
表4.4.1 研究樣本人口學及疾病屬性（依診斷分組）……………………………51
表4.4.2 癌症病童診斷與死亡前住院及化療情形相關性分析……………………52
表4.4.3 癌症病童診斷與癌症末期過度醫療指標相關性分析……………………52
表4.4.4 癌症病童診斷與死亡前醫療處置相關性分析……………………………53
表4.4.5 癌症病童診斷與DNR簽署情形相關性分析 ……………………………54
表4.4.6 癌症病童診斷與安寧緩和療護使用情形相關性分析……………………55
表4.4.7 研究樣本人口學及疾病屬性（依性別分組）……………………………57
表4.4.8 癌症病童性別與死亡前住院及化療情形相關性分析……………………58
表4.4.9 癌症病童性別與癌症末期過度醫療指標相關性分析……………………58
表4.4.10 癌症病童性別與臨終醫療處置情形相關性分析 ………………………59
表4.4.11 癌症病童性別與DNR簽署情形相關性分析……………………………60
表4.4.12 癌症病童性別與安寧緩和療護使用情形相關性分析 …………………61
表4.4.13 研究樣本人口學及疾病屬性（依獨生子女分組） ……………………63
表4.4.14 獨生子女與死亡前住院及化療情形之相關性分析 ……………………64
表4.4.15 獨生子女與癌症末期過度醫療指標之相關性分析 ……………………64
表4.4.16 獨生子女與臨終醫療處置情形之相關性分析 …………………………65
表4.4.17 獨生子女與DNR簽署情形之相關性分析………………………………66
表4.4.18 獨生子女與安寧緩和療護使用情形之相關性分析 ……………………67
表4.4.19 研究樣本人口學及疾病屬性（依死亡年齡分組） ……………………69
表4.4.20 癌症病童死亡年齡與死亡前住院及化療情形相關性分析………………70
表4.4.21 癌症病童死亡年齡與癌症末期過度醫療指標指標相關性分析…………70
表4.4.22 癌症病童死亡年齡與臨終醫療處置情形相關性分析……………………71
表4.4.23 癌症病童死亡年齡與DNR簽署情形相關性分析 ………………………72
表4.4.24 癌症病童死亡年齡與安寧緩和療護使用情形相關性分析………………73
表4.4.25 研究樣本人口學及疾病屬性（依罹病期間分組）………………………75
表4.4.26 癌症病童罹病期間與死亡前住院及化療情形相關性分析………………76
表4.4.27 癌症病童罹病期間與癌症末期過度醫療指標相關性分析………………76
表4.4.28 癌症病童罹病期間與臨終醫療處置情形相關性分析……………………77
表4.4.29 癌症病童罹病期間與DNR簽署情形相關性分析 ………………………78
表4.4.30 癌症病童罹病期間與安寧緩和療護使用情形相關性分析………………79
表4.4.31 研究樣本人口學及疾病屬性（依死亡年齡及診斷分組）………………81
表4.4.32 癌症病童死亡年齡及診斷與死亡前住院及化療情形相關性分析………82
表4.4.33 癌症病童死亡年齡及診斷與癌症末期過度醫療指標相關性分析………82
表4.4.34 癌症病童死亡年齡及診斷與臨終醫療處置情形相關性分析……………83
表4.4.35 癌症病童死亡年齡及診斷與DNR簽署情形相關性分析 ………………84
表4.4.36 癌症病童死亡年齡及診斷與安寧緩和療護使用情形相關性分析………85
表4.5.1 研究樣本人口學及疾病屬性（依照會情形分組） ………………………88
表4.5.2 照會情形與死亡前住院及化療情形相關性分析 …………………………89
表4.5.3 照會情形與癌症末期過度醫療指標相關性分析 …………………………89
表4.5.4 照會情形與死亡前醫療處置相關性分析 …………………………………90
表4.5.5 照會情形與DNR簽署情形相關性分析……………………………………91
表4.5.6 研究樣本人口學及疾病屬性（依共照情形分組） ………………………93
表4.5.7 收案情形與死亡前住院及化療情形相關性分析 …………………………94
表4.5.8 收案情形與癌症末期過度醫療指標相關性分析 …………………………94
表4.5.9 收案情形與臨終醫療處置情形相關性分析 ………………………………95
表4.5.10 收案情形與DNR簽署情形相關性分析 …………………………………96


圖目錄
圖1 癌症病童生命末期照護現況研究架構…………………………………………20
圖2 癌症病童生命末期照護現況資料收集過程……………………………………24

中文部分
中華民國兒童癌症基金會（2011）．90-99各年度新發病病童人數統計圖．取自http://www.ccfroc.org.tw/child/child_census_read.php?s_id=27
全國法規資料庫（2002）．安寧緩和醫療條例．取自http://law.moj.gov.tw/
行政院衛生署（2011）．民國99年死因摘要表．取自http://www.doh.gov.tw/CHT2006/DM/DM2_2_p02.aspx?class_no=440&now_fod_list_no=11962&level_no=4&doc_no=81294
行政院衛生署中央健康保險局（2009）．全民健康保險支付標準98.10.30更新版．取自http://www.nhi.gov.tw/
行政院衛生署中央健康保險局（2011）．全民健康保險安寧共同照護試辦方案．取自http://www.nhi.gov.tw/information/bbs_detail.aspx?bulletin_ID=1404&menu=9&menu_id=545
杜晶瑩（2006）．探討癌症病童臨終階段的醫療照護 - 2002~2003病歷回顧（未發表的碩士論文）．台北市：國立台灣大學護理學研究所。
呂立（2011）．兒童安寧緩和醫療概論．取自 http://epaper.ntuh.gov.tw/health/201112/child_1.html
呂佩紋、黃棣棟、穆佩芬（2011）．護理人員照顧癌症病童臨終時的經驗．護理雜誌，58（4），37-46。doi:10.6224/JN.58.4.37
許馨文、胡文郁、程劭儀、姚建安、陳慶餘、邱泰源（2005）．某緩和病房小兒癌末病人善終服務．安寧療護雜誌，10（4），358-370。
張育菁（2009）．探討某醫學中心新生兒加護病房之臨終照護（未發表的碩士論文）．台北市：台北醫學大學護理學研究所。
莊榮彬（2005）．安寧共同照顧簡介．安寧療護雜誌，10（1），39-43。
黃冠棠（2005）．九十四年度台大醫院安寧共同照護計畫期中報告．台北市：行政院衛生署國民健康局。
陳韵宜（2006）．癌症兒童生命末期照護型態相關因素之探討（碩士論文）．取自華藝線上圖書館。
陳思蓉（2011）．以個案研究法分析某醫學中心兒童癌症末期照護服務（碩士論文）．取自華藝線上圖書館。
陳瑞儀（2007）．由癌末病人家屬看安寧共同照護模式下末期照護品質之研究（碩士論文）．取自華藝線上圖書館。
葉青宜（2010）．安寧共同照護計畫對安寧療護利用之影響（碩士論文）．取自華藝線上圖書館。
曾鈺琇（2011）．父母與臨終子女身體接觸的經驗（碩士論文）．取自華藝線上圖書館。
趙可式（2009）．台灣地區安寧緩和療護的發展與前瞻．護理雜誌，56（1），5-10。doi:10.6224/JN.56.1.5
樓曉玲（2007）．腦瘤病童疾病末期母親預期性失落之生活經驗（未發表的碩士論文）．台北市：陽明大學臨床護理研究所。

英文部分
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