臺灣博碩士論文加值系統

背景：台灣的護理之家主要服務群體多為失能老人及其家庭，然老年期正是臨近死亡之人生階段，能否善終為一重要議題，卻罕有文獻探討護理之家老年住民不施行心肺復甦術決策意向之影響因子。因此，本研究旨在探討老年住民及其代理家屬，對於老年住民接受不施行心肺復甦術與否之決策與意向上之影響因素。
方法：本研究採橫斷式相關性研究設計，自北部某地區醫院護理之家，立意取樣65歲(含)以上老年住民及其代理家屬(n = 177)，研究工具為巴氏量表、攜帶式簡短心智量表、老人憂鬱量表、及自擬結構式問卷，透過病歷回顧及問卷訪談收集資料，包含老年住民特質、代理家屬屬性、不施行心肺復甦術決策意向之現況，並運用統計軟體SPSS 15.0版進行資料分析，以多變項邏輯式迴歸探討老年住民不施行心肺復甦術決策/意向之預測因子。
結果：在不施行心肺復甦術之決策方面，老年住民不施行心肺復甦術之意願書/同意書簽署比率低(9%)，且由家屬代理不施行心肺復甦術簽署(79%)之現象普遍。而老年住民不施行心肺復甦術之決策預測因子，包含老年住民年齡(OR = 1.16, 95% CI = 1.05 - 1.28)、離婚及鰥寡之老年住民(OR = 7.95, 95% CI = 1.33 - 47.72)、罹患癌症者(OR = 9.70, 95% CI = 1.59 - 59.10)、肺部疾病者(OR = 5.44, 95% CI = 1.29 - 22.94)、骨骼肌肉系統疾病者(OR = 4.82, 95% CI = 1.12 - 20.75)。另在老年住民不施行心肺復甦術之意向方面，有56.7%老年住民及76.9%代理家屬，均贊成為老年住民簽署不施行心肺復甦術，而老年住民不施行心肺復甦術之意向預測因子，僅全家有達成共識(OR = 28.80, 95% CI = 2.43 - 341.09)為統計上顯著之影響因子。
結論：本研究中護理之家老年住民大多有認知功能缺損，其不施行心肺復甦術決策亦多為家屬代理，且有接受不施行心肺復甦術意向高而實際決策低之落差，而促成全家共識實為老年住民不施行心肺復甦術之關鍵，如何落實於護理之家之老年期照護，未來可以質性研究就老年住民及代理家屬的觀點更進一步探討，於老年住民及其家庭成員間，既尊重老年人的自主決策，亦能及早決策與建置生命末期照護計畫，更提升現今長期照護體系下本土化善終之照護品質。

Background: The majority of service population of Taiwan’s nursing homes are disabled senior residents. The elderly stage is approaching the stage of death. A good death is a critical issue for disabled senior residents. However, the affecting factors of do-not-resuscitate (DNR) decision or intention among disabled senior residents at nursing homes are rarely explored in the literature. This study was to investigate the factors associated with the DNR decision or intention among elderly nursing home residents in Taiwan.
Methods: This was a cross-sectional and correlational study design using a purposive sampling to recruit ≧ 65 year-old residents and their family(n = 177) from a nursing home of the district hospital in northern Taiwan. The measurement tools included Barthel Index, Short Portable Mental Status Questionnaire, Geriatric Depression Scale, and self-designed constructive questionnaires. Data were collected by questionnaires, face to face interview, and medical chart review including characteristics of elderly residents and family surrogates and DNR decision or intention. Data were analyzed using multivariate logistic regressions of SPSS 15.0.
Results: Only 9% of senior residents signed DNR. The majority of family (79%) surrogates made the DNR decision for senior residents. Multivariate logistic regression showed that resident’s age (OR = 1.16, 95% CI = 1.05 - 1.28), divorced and widowed residents (OR = 7.95, 95% CI = 1.33 - 47.72), resident with cancer (OR = 9.70, 95% CI = 1.59- 59.10), lung disease (OR = 5.44, 95% CI = 1.29 - 22.94), or muscle and skeletal disease (OR = 4.82, 95% CI = 1.12 - 20.75) were significant predictor for resident’s DNR decision. In addition, most elderly (56.7%) and their family surrogates (76.9%) agreed with signed DNR for senior residents. Family consensus of DNR (OR = 28.80, 95% CI = 2.43 - 341.09) was the only significant factor associated with resident’s DNR intention.
Conclusions: Most elderly residents of nursing homes were cognitive impairment and their DNR decisions were made by family surrogates. There was a discrepancy between senior residents and their family proxies on DNR decision and intention. Facilitating family consensus on resident’s DNR to making actual DNR decision and end-of-life care are important for nursing home elderly residents. Future studies can conduct a qualitative study to understand elderly resident’s and family proxy’s perspectives and to establish advanced care planning early. Thus, the end-of-life care was determined by elderly resident’s self-determination.

口試委員會審定書 2
致 謝 3
中文摘要 4
Abstract 6
第一章 緒論 10
第一節 研究背景與動機 10
第二節 研究之重要性 12
第三節 研究問題與目的 13
第四節 研究假設 13
第二章 文獻查證 15
第一節 護理之家老年住民之特質 15
第二節 家屬對老年住民之照顧決策 18
第三節 老年住民不施行心肺復甦術與決策意向之影響因素 19
第三章 方法 30
第一節 研究設計 30
第二節 研究架構 30
第三節 研究樣本和場所 31
第四節 研究工具 32
第五節 名詞界定 35
第六節 變項定義 36
第七節 研究步驟 39
第八節 資料分析 41
第九節 倫理考量 42
第四章 研究結果 43
第一節 老年住民之特質 43
第二節 代理家屬之屬性 43
第三節 老年住民不施行心肺復甦術之決策意向現況 51
第四節 老年住民不施行心肺復甦術決策意向之盛行率、差異和ㄧ致性 55
第五節 老年住民特質和代理家屬屬性對老年住民DNR決策意向之影響 55
第五章 討論 62
第一節 老年住民不施行心肺復甦術之決策意向與現況 62
第二節 老年住民不施行心肺復甦術之決策意向差異性 63
第三節 老年住民不施行心肺復甦術之決策預測因子 64
第四節 老年住民不施行心肺復甦術之意向預測因子 66
第五節 結論 66
第六節 護理應用 67
第七節 研究限制 68
參考文獻 69
附錄一、長庚醫院人體試驗倫理委員會同意證明 76
附錄二、桃園分院(長青院區) 老年住民受訪同意書 77
附錄三、桃園分院(長青院區) 代理家屬受訪同意書 81
附錄四、長庚護理研究委員會同意收案證明 85
附錄五、攜帶式簡短心智量表之研究工具授權書 86
附錄六、自擬問卷專家內容效度之專家名單 87
附錄七、自擬問卷專家內容效度評分量表 88
附錄八、老年住民特質調查表 95
附錄九、代理家屬屬性調查表 96
附錄十、不施行心肺復甦術之決策意向影響因素調查表(老年住民版) 97
附錄十一、不施行心肺復甦術之決策意向影響因素調查表(代理家屬版) 99
附錄十二、日常生活功能評量表 101
附錄十三、攜帶式簡短心智量表 103
附錄十四、簡明版老年憂鬱量表 104
附錄十五、統計假說檢測摘要表 105
附錄十六─一、DNR決策(decisions)之雙變項邏輯式迴歸標準模型分析 111
附錄十六─二、DNR決策(decisions)之多變項邏輯式迴歸標準模型分析 113
附錄十七─一、DNR意向(Intention)之雙變項邏輯式迴歸標準模型分析 114
附錄十七─二、DNR意向(Intention)之多變項邏輯式迴歸標準模型分析 118

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