臺灣博碩士論文加值系統

本研究目的為瞭解癌患死亡前之疼痛處理品質，並比較接受安寧與非安寧照護癌患在疼痛處理品質的差異。採回顧病歷之回溯性研究設計，以分層隨機抽樣方式抽取某醫療體系在北部的三間醫院511位於2011年死亡的癌患之樣本（非安寧組307人，安寧組204人）。研究工具包含基本人口學問卷、止痛藥物使用紀錄單與癌症疼痛處理品質指標。
結果發現：過程品質指標的總達成率為17.6%，在11項的過程指標中，有二項達成率超過50%：「中重度疼痛的再評估」及「使用鴉片類止痛藥時開立腸道處方」；另有四項達成率不及10%：「完整性疼痛評估-其他要項」、「藥物副作用的評估」、「非藥物性處置」與「對病人或家屬的疼痛衛教」。
在結果指標（疼痛緩解程度）方面，與疼痛發生時的疼痛強度相比，疼痛發生後72小時的疼痛強度平均減少1.02分( SD= 3.56)，而死亡前三天疼痛強度平均增加0.13分( SD= 2.97)。多變量分析發現，安寧組與非安寧組僅在兩項過程指標的達成率有差異：「入院或疼痛發生時使用疼痛量表評估痛疼」與「使用鴉片類止痛藥有開立腸道處方」。

This study aimed to understand the quality of pain management for patients with cancer before death and to compare the quality of pain management between patients receiving hospice and non-hospice care. This study used retrospective chart review design. A stratified random sampling was used to draw a sample of 511 cancer patients (non-hospice = 307, hospice = 204) who died in 2011 from three hospitals of the same medical system located in northern Taiwan. The data collection tools included demographic questionnaire, analgesics use form, and quality indicators for cancer pain management.
The results showed that the overall achievement rate for process quality indicators was 17.6%. Among the 11 process indicators, two had more than 50% of patients reached the standard: "re-assessment for moderate to severe pain" and "bowel regiment initiated for patients with opioids”. Four indicators had less than 10% of patients met the standards: "comprehensive assessment-other", "analgesic side effects monitored", "non-pharmacological therapies used" and "pain education to patients or families".
Regarding the outcome indicators (i.e., pain relief), compared to the initial pain intensity, the averaged 72-hour pain intensity reduced by 1.02 points (SD = 3.56). However, the averaged pain intensity within 3 days before death increased by 0.13 points (SD = 2.97). The multivariate analysis showed that patients receiving hospice and non-hospice care only differed on two process quality indicators: "use of valid pain scale at admission or initial pain" and "bowel regiment initiated for patients with opioids".

目 錄
指導教授推薦書
口試委員審定書
授權書 iii
致謝 iv
中文摘要 v
英文摘要 vi
目錄 vii
表目錄 ix
圖目錄 xii

第一節 緒論 1
第一節 研究動機與重要性 1
第二節 研究目的 4
第三節 研究問題 5
第四節 名詞定義 6
第二節 文獻查證 7
第一節 癌末疼痛概述 7
第二節 癌症疼痛處理準則 9
第三節 監測癌症疼痛處理品質指標之工具 14
第四節 依據準則改善癌症疼痛之實證研究結果 20
第五節 影響癌症病患疼痛處理品質之因素 22
第六節 安寧與非安寧照護之疼痛處理品質之比較 26
第七章 總結 28
第三章 研究方法 29
第一節 研究架構 29
第二節 研究設計 30
第三節 研究場所與對象 31
第四節 樣本數估計 32
第五節 研究工具 33
第六節 資料收集過程 38
第七節 資料統計與分析 41
第八節 倫理考量 43
第四章 研究結果與分析 44
第一節 死亡癌患基本人口學特性與疾病治療特性之統計分析 44
第二節 死亡癌患疼痛處理品質 52
第三節 影響癌症疼痛處理品質之因素 62
第四節 接受非安寧與安寧照護的死亡癌患之疼痛處理品質 96
第五章 討論 109
第一節 癌症病患疼死亡前的疼痛處理品質 109
第二節 癌症病患疼痛處理品質的影響因素 114
第三節 安寧組與非安寧組癌症病患死亡前的疼痛處理品質之差異 116
第六章 結論與建議 118
第一節 結論 118
第二節 護理的應用 120
第三節 研究限制與建議 122
參考文獻 123
附錄 135

表目錄
表2-1癌症疼痛處理品質指標之工具 17
表3-1統計分析方法 41
表4-1 死亡癌患基本人口學資料 47
表4-2疾病治療特性 48
表4-3疼痛處理品質評估期間的住院單位屬性 51
表4-4A癌症疼痛處理品質過程指標達成情形 57
表4-4B癌症疼痛處理品質結果指標之疼痛緩解情形 60
表4-5疼痛發生後72小時及死亡前三天的疼痛程度變化 61
表4-6比較性別在癌症疼痛處理品質過程指標總達成率與疼痛緩解度之差異 67
表4-7比較性別在疼痛處理品質過程指標之差異 68
表4-8年齡與癌症疼痛處理品質過程指標總達成率與疼痛緩解度之關係 69
表4-9年齡與癌症疼痛處理品質過程指標之關係 70
表4-10比較不同教育程度在癌症疼痛處理品質過程指標總達成率與疼痛緩解度之差異 72
表4-11比較不同教育程度對癌症疼痛處理品質過程指標之差異 73
表4-12比較不同的ECOG在癌症疼痛處理品質過程指標總達成率與疼痛緩解度之差異 75
表4-13比較ECOG在癌症疼痛處理品質過程指標之差異 76
表4-14共病症數目與癌症疼痛處理品質過程指標總達成率與疼痛緩解度之關係 77
表4-15共病症數與癌症疼痛處理品質過程指標之關係 78
表4-16比較不同癌症診斷在癌症疼痛處理品質過程指標總達成率與疼痛緩解度之差異 80
表4-17比較不同癌症診斷在癌症疼痛處理品質過程指標之差異 82
表4-18不同癌症期別在癌症疼痛處理品質過程指標總達成率與疼痛緩解度之差異 85
表4-19不同癌症期別在疼痛處理品質過程指標之比較 86
表4-20比較死亡前最後一個月是否接受抗癌治療在癌症疼痛處理品質過程指標總達成率與疼痛緩解度之差異 87
表4-21比較死亡前最後一個月是否接受抗癌治療在疼痛處理品質過程指標之差異 88
表4-22病房別在癌症疼痛處理品質過程指標總達成率與疼痛緩解度之差異 89
表4-23病房別在癌症疼痛處理品過程指標質之差異 90
表4-24比較不同的主治醫師背景在疼痛處理品質過程指標指標總達成率與疼痛緩解度之差異 92
表4-25 比較不同主治醫師背景在疼痛處理品質過程指標之差異 93
表4-26比較非安寧組與安寧組在癌症疼痛處理品質過程指標總達成率與疼痛緩解度之差異 94
表4-27比較非安寧組與安寧組在疼痛處理品質過程指標之差異 95
表4-28癌症疼痛處理品質過程指標總達成率之多元迴歸分析 99
表4-29癌症疼痛處理品質指標1達成率之邏輯斯迴歸分析 100
表4-30癌症疼痛處理品質指標2達成率之邏輯斯迴歸分析 101
表4-31癌症疼痛處理品質指標3達成率之邏輯斯迴歸分析 102
表4-32癌症疼痛處理品質指標4達成率之邏輯斯迴歸分析 103
表4-33癌症疼痛處理品質指標5達成率之邏輯斯迴歸分析 104
表4-34癌症疼痛處理品質指標8達成率之邏輯斯迴歸分析 105
表4-35癌症疼痛處理品質指標9達成率之邏輯斯迴歸分析 106
表4-36癌症疼痛處理品質死亡前三天緩解程度之多元迴歸分析 108

圖目錄
圖3-1研究架構圖 29
圖3-2 抽樣流程圖 39
圖3-3 病歷審查流程圖 40

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