臺灣博碩士論文加值系統

依據衛福部公布資料，事故傷害是國人十大死因中，導致70 歲以下人口平均生命年數損失最高的原因。嚴重的頭部外傷更是造成事故傷害死亡的重要原因。此類病患不論是否積極接受積極治療，其癒後死亡率高或常存有嚴重身體及意識障礙，需後續長期的照顧支持及醫療資源的耗用，在國外常被認定是無效醫療，常採用安寧緩和療法，撤除維生醫療器材。 本研究樣本收集南部某一級外傷中心2011-2015年登錄之嚴重頭部外傷病患，以回溯方式收集病歷資料，共收錄155位病例。病人當次出院狀態有70（45.2%）名死亡、51（32.9%）名留有明顯障礙、34（21.9%）名無明顯障礙。依出院狀況分組分析醫療資源耗用，留有明顯殘障的組別平均住院天數39.7日、平均加護病房住院天數19.54日、及平均健保支付總費499,262元，明顯高於無明顯殘障的組別（25.17日、12.14日、295,240元），更高於死亡組（6.26日、6.06日、143,388元）。六個月後的恢復功能評估，預後不良的也就是GOS≦3分的病患有121（78.1%）名、存有輕微障礙的GOS 4 分的病患有15（9.7%）位、恢復正常的GOS 5分有19（12.3%）位。對於拒絕瀕死前急救，簽署DNR同意書的部分，67（43.2%）位病患於死亡前，病患家屬有簽署同意書，但只有7（4.5%）接受積極性的移除維生器材處置。為降低對於嚴重頭部外傷無效醫療，病人生前的預立醫囑、病人自主權利法及醫療人員對於末期疾病的共識是可以改善的方法。

According to the data of Ministry of Health and Welfare (Taiwan), accident injury, as one of the top ten leading cause of death in Taiwan, caused the highest life expectancy loss for the age below 70 years old. Severe head injury is important cause of death after accident injury. Prognosis with high mortality rate and severe residual physical or cognitive disability was noted after treatment. Long term care and large amount of medical resource utilization are required for patients with severe disability. Medical care for severe head injury patients were considered as futile and palliative care even life support withdraw was regarded frequently. In this study, we collected 155 registered severe head injury patients from a level I trauma center in south Taiwan from 2011 to 2015. We retrospectively collected data from charts review. The patients discharge status presented 70 (45.2%) mortality, 51 (32.9%) severe disability and 34 (21.9%) without disability. We also analyzed medical resource utilization in those patients, which included average of total length of stay, length of stay in intensive care center and expenses. The average period of total length of stay in severe disability group is 39.7 days, 19.54 days for length of stay in intensive care unit and 499,262 NTDs average expenses. They was all higher than the patients without severe disability (25.17days, 12.14days and 295,240 NTDs) and the mortality group (6.26 days, 6.06 days and 143,388 NTDs). Function recovery outcome was evaluated six months later after injury. The data showed 121 (78.1%) patients were in poor prognosis (GOS≦3), 15 (9.7%) patients were in moderate disability (GOS=4) and 19 (12.3%) patients were without disability with (GOS=5). For DNR permit signature, 67(43.2%) permits were signed by patients’family. Only 7(4.5%) agreed life support withdrawal. In order to reduce futile care for patients with severe head injury, we recommend promoting patient living will, Patient Self-Determination Act and the consensus for caregiver about terminal disease.

論文審定書 i
誌謝 ii
中文摘要 iii
ABSTRACT v
目錄 viii
第一章 緒論 1
第一節 研究背景與動機 1
第二章 文獻查證 6
第一節 頭部外傷的原因及其相關之醫療資源耗用 6
第二節 頭部外傷的治療與癒後 7
第三節 國外對於頭部外傷安寧和緩和醫療的情形 9
第四節 國內對於頭部外傷安寧和緩和醫療的情形 11
第五節、無效醫療對醫療資源耗用的影響 12
第三章 研究方法 14
第一節 研究對象及資料收集 14
第二節 研究變數 14
第三節 統計分析方法 17
第四章 研究結果 19
第一節 樣本分析結果 19
第二節 檢定分析結果 21
第五章 討論與建議 27
第六章 研究限制及未來研究 32
參考文獻 34
一. 中文文獻……..…………………………………… …34
二. 英文文獻……………………..……………………… 36
附件1.. 全民健保適用非癌症與運動神經元疾病末期之其他末期病人（八大類）…………………………………………….……………………………………… 39
附件2. 安寧緩和醫療條例 41
附件3. 病人自主權利法…………………………………… 44
附件 4. CRASH Head injury prognosis 網頁….……… 47
附件 5. Impact Prognosis calculator 網頁…………….… 48

參考文獻

一. 中文文獻

1. 紀煥廷、邱文達、楊大羽、蔡行瀚（2009）。台北市輕度頭部外傷之流行病學及醫療資源使用情形。中華民國急救加護醫學會雜誌，18(2)，61-70。
2. 王雅鈴(2006)。探討頭部外傷的傷害機轉與醫療資源耗用 (碩士論文)。台灣博碩士論文加值系統 (Retrieved Jan.17, 2018,from http://hdl.handle.net/11296/g34aqt) 。
3. 洪美香(2008)。頭部外傷住院病患醫療資源耗用及其相關因素之探討 (碩士論文)。台灣博碩士論文加值系統 (Retrieved Jan.17, 2018,from http://hdl.handle.net/11296/4hs9fk) 。
4. 陳俊甫(2003)。嚴重頭部外傷處理準則對台灣地區病患存活情形之評估(碩士論文)。台灣博碩士論文加值系統 (Retrieved Jan.17, 2018,from http://hdl.handle.net/11296/35b88a ) 。
5. 林志隆(2011)。頭部外傷病人之預後與醫療資源使用情形 (碩士論文) 台灣博碩士論文加值系統 (Retrieved Jan.17, 2018,from http://handle.ncl.edu.tw/11296/rk9sy9 ) 。
6. 吳春桂 蘇玲華 黃勝堅(2009)。“DNR”知情告知與決策對於重症生命末期照護之重要性。安寧療護，14：172-85。

7. 蔡翊新 林亞陵 黃勝堅(2007)。重症病患之生命末期照護。安寧療護，12：312-20。

8. 楊志良(2011)。全民健保的迷思。科學人， 111(8)。
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10. 唐高駿、藍祚運(2014)。臨終前無效醫療研究報告書 - 393公民平台（Retrieved Jan.17, 2018,from http://www.393citizen.com/file.php?n=upload/2014_11_11_14_16_50.pdf&txt=medical futile report..pdf）。

















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