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研究生:高綺吟
研究生(外文):Chi-Yin Kao
論文名稱:安寧共同照護模式對提升癌末照護品質之成效
論文名稱(外文):The Effects of Hospital-based Palliative Care Team on Quality of Care with Terminal Cancer
指導教授:胡文郁胡文郁引用關係
指導教授(外文):Wen-Yu Hu
學位類別:碩士
校院名稱:國立臺灣大學
系所名稱:護理學研究所
學門:醫藥衛生學門
學類:護理學類
論文種類:學術論文
論文出版年:2007
畢業學年度:95
語文別:中文
論文頁數:139
中文關鍵詞:安寧共同照護模式癌末照護品質症狀困擾憂鬱
外文關鍵詞:hospital-based palliative care teamterminal cancerquality of caresymptom distressdepression
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  • 被引用被引用:25
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本研究目的為探討安寧共同照護模式對提升癌末照護品質之成效。採準實驗設計(quasi-experimental design),自2005年11月至2006年7月止,於北臺灣某醫學中心進行資料收集,採症狀困擾量表、醫院焦慮憂鬱量表、靈性安適狀態量表及社會支持量表予以病人前測,施測後依照護模式的不同,分為原單位治療且未接受安寧共同照護模式(31位)、原單位治療但有接受安寧共同照護模式(33位)以及直接轉入安寧病房(36位)三組。一週後,再以相同量表進行後測,以瞭解安寧共同照護模式的照護品質之成效。
重要研究結果發現,癌末病人之照護問題呈多面向,其中前三項主要問題分別為生理 (60%)、心理 (58%)以及病情告知(24%)問題。生理問題的發生頻率以疲倦、口乾、疼痛、食慾不振及腹脹最常見,困擾度由高而低依序為腹水、疼痛、大小便失禁、疲倦及食慾不振;心理問題以癌末病人疑似有憂鬱狀態為主(平均分數為8.84分)。此外,安寧共同照護模式確實能有效改善症狀困擾、焦慮及憂鬱狀態,並且提高靈性安適狀態、社會支持度以及簽署DNR比例。結果也發現得知病情者比未知病情者較不焦慮且靈性安適狀態較佳。且癌末病人知不確定感與病情認知度及靈性安適狀態呈負相關,與焦慮呈正相關;症狀困擾總數則與焦慮呈正相關、與靈性安適呈負相關;焦慮與憂鬱呈正相關;靈性安適狀態與焦慮及憂鬱成負相關,與社會支持呈正相關。簽署DNR組之癌末照護品質較未簽署DNR組佳。
故安寧共同照護模式能顯著且有效地緩解病人的症狀困擾、降低焦慮及憂鬱程度、提升靈性安適狀態、增加社會支持度及簽署DNR比例,為臨床實務中值得推廣的末期醫療照護模式。
The primary aim of the study was to explore the effects of hospital-based palliative care team on quality of care with terminal cancer. Pretest-posttest quasi experimental design was adopted. Between November 2005 through July 2006, we investigated 100 eligible patients with terminal cancer in a medical center in north of Taiwan. 33 patients received hospital-based palliative care team services compared with 31 patients receiving traditional supportive care and 36 patients admitted to palliative care unit directly. Data was collected using the questionnaires include “Symptom Distress Scale, Hospital Anxiety and Depression Scale, Spiritual Well-Being Scale and Social Supportive Scale” on two occasions.
The main needs for terminal cancer patients’ care were physical care (60%), psychological care (58%) and truth telling (24%). Fatigue, dry mouth, pain, loss of appetite, and abdominal distention were common physical symptoms. Ascites, pain, feces and urine incontinence, fatigue, and appetite loss were most distressed for physical symptoms. Depression was a significant symptom in psychological problem (mean score was 8.84). There were significant improvements in physical symptoms, anxiety and depression, spiritual well-being, social support and DNR approval in hospital-based palliative care team. Truth telling was also significant reduction in anxiety degree and improvements in spiritual well-being. Truth telling and uncertainty were negatively correlated. Uncertainty and anxiety were positively correlated, but uncertainty and spiritual well-being were negatively correlated. Amounts of symptoms and anxiety were positively correlated, but amounts of symptoms with spiritual well-being were negatively correlated. Anxiety and depression were positively correlated, but anxiety with spiritual well-being was negatively correlated. Depression and spiritual well-being were negatively correlated. Quality of care with patients whose DNR consent form orders were signed was greater than patients not signed DNR consent form.
In conclusion, hospital-based palliative care team improved symptoms, anxiety and depression, spiritual well-being, social support and DNR approval in patients with terminal cancer.
第壹章 緒論
第一節 研究背景與重要性………………………………………1
第二節 研究目的…………………………………………………4
第三節 研究假設…………………………………………………5
第四節 名詞定義…………………………………………………6
第貳章 文獻查證
第一節 癌末的定義………………………………………………8
第二節 癌末病人的整體痛苦與照護需求………………………11
一、生理方面……………………………………………………11
二、心理方面……………………………………………………12
三、靈性方面……………………………………………………13
四、社會支持方面………………………………………………14
第三節 安寧共同照護模式………………………………………16
一、癌末病人的臨床照護模式…………………………………16
二、安寧共同照護模式…………………………………………19
三、國外安寧共同照護模式之經驗與研究……………………23
第四節 末期照護品質……………………………………………25
一、品質及照護品質……………………………………………25
二、末期照護品質………………………………………………26
三、DNR與末期照護品質………………………………………27
四、末期照護品質的測量指標…………………………………29
第五節 測量工具的選擇…………………………………………33
一、症狀困擾量表………………………………………………33
二、焦慮量表……………………………………………………35
三、憂鬱量表……………………………………………………37
四、靈性量表……………………………………………………39
五、社會支持量表………………………………………………42
第叁章 研究方法
第一節 研究設計…………………………………………………44
第二節 研究對象與場所…………………………………………45
第三節 研究工具的信效度………………………………………46
第四節 資料收集過程……………………………………………50
第五節 資料分析方法……………………………………………51
第六節 倫理考量…………………………………………………52
第肆章 結果
第一節 癌末病人照護需求的現況………………………………53
ㄧ、基本資料……………………………………………………53
二、生理及心理層面……………………………………………57
三、靈性及社會層面……………………………………………57
第二節 安寧共同照護模式對癌末照護品質成效………………64
ㄧ、症狀困擾……………………………………………………64
二、焦慮憂鬱……………………………………………………64
三、靈性安適狀態………………………………………………65
四、社會支持……………………………………………………65
五、DNR及CPR狀態……………………………………………66
第三節 病情認知度與癌末照護品質的關係……………………79
ㄧ、病情認知度對癌末照護品質的影響………………………81
二、病情認知度與癌末照護品質的相關性……………………81
第四節 簽署DNR對癌末照護品質的影響………………………84
ㄧ、簽署DNR對癌末照護品質的影響…………………………84
二、病人自主簽署DNR對癌末照護品質的影響………………87
第伍章 討論
第一節 華人文化對病情告知之影響……………………………90
第二節 多專業團隊合作於癌末照護之重要性…………………92
第三節 安寧共同照護模式推展之可行性………………………95
一、安寧共同照護模式的重要性………………………………95
二、我國推展安寧共同照護模式的限制………………………98
第四節 病情認知度與DNR對癌末照護品質的影響…………100
第陸章 結論與建議
第一節 結論……………………………………………………102
第二節 護理應用………………………………………………103
第三節 限制與建議……………………………………………104


參考文獻
中文部份…………………………………………………………105
英文部份…………………………………………………………108


附錄
附錄一 問卷基本資料……………………………………………118
附錄二 症狀困擾量表……………………………………………119
附錄三 醫院焦慮憂鬱量表………………………………………120
附錄四 靈性安適狀態量表………………………………………121
附錄五 社會支持量表……………………………………………122
附錄六 量表授權使用同意書……………………………………123
附錄七 內容效度專家名單………………………………………135
附錄八 專家內容效度檢核………………………………………136
附錄九 受訪者同意書……………………………………………138
附錄十 台大醫院人體試驗委員會審查合格證明………………139


圖表目次
圖2-1 安寧共同照護小組作業流程………………………………………22
表2-1 各學者對疾病末期的定義…………………………………………10
表2-2 癌末病人之照護指標………………………………………………32
表2-3 症狀困擾相關測量工具之比較分析與選擇………………………34
表2-4 焦慮相關測量工具之比較分析與選擇……………………………36
表2-5 憂鬱相關測量工具之比較分析與選擇……………………………38
表2-6 癌末病人靈性相關測量工具之比較分析與選擇…………………40
表2-7 靈性量表信效度內容比較…………………………………………41
表2-8 社會支持度量表信效度內容比較…………………………………43
表3-1 各量表之信效度……………………………………………………49
表4-1 基本資料同質性檢定………………………………………………54
表4-2 各次量表同質性檢定(前測)……………………………………55
表4-3 各量表單題同質性檢定(前測)…………………………………56
表4-4 症狀困擾發生率(前測)…………………………………………59
表4-5 症狀困擾困擾度(前測)…………………………………………60
表4-6 焦慮次量表得分及排序(前測)…………………………………61
表4-7 憂鬱次量表得分及排序(前測)…………………………………61
表4-8 靈性安適狀態量表得分及排序(前測)…………………………60
表4-9 社會支持量表得分及排序(前測)………………………………63
表4-10 三組照護模式對癌末照護品質之成效(各次量)………………67
表4-11 三組照護模式對癌末照護品質之成效(症狀困擾度)…………69
表4-12 三組照護模式對癌末照護品質之成效(焦慮次量表)…………71
表4-13 三組照護模式對癌末照護品質之成效(憂鬱次量表)…………72
表4-14 三組照護模式對癌末照護品質之成效(靈性安適狀態量表)…73
表4-15 三組照護模式對癌末照護品質之成效(社會支持量表)………76
表4-16 癌末病人簽署DNR的情形…………………………………………78
表4-17 癌末病人接受CPR的情形…………………………………………78
表4-18 病情了解度之同質性檢定(前後測)……………………………80
表4-19 依病情認知度分組的各次量表同質性檢定(前測)……………80
表4-20 依病情認知度分組的癌末照護品質(各次量表)………………82
表4-21 病情了解與不確定感與前測身心靈及社會支持的相關性………83
表4-22 共同照護組是否簽署DNR的前測各次量表之同質性檢定………85
表4-23 共同照護組是否簽署DNR的的癌末照護品質(各次量表)……86
表4-24 安寧病房組簽署DNR者的前測各次量表同質性檢定……………88
表4-25 安寧病房組簽署DNR者的癌末照護品質(各次量表)…………89
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