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研究生:廖綠
研究生(外文):Liao, Lu
論文名稱:護理之家住民不施行心肺復甦術現況簽署/不簽署影響因子探討
論文名稱(外文):The Current Status and Fatcors Affecting Endorsement of “Do-Not-Resuscitate” for Patients of Long Term Care Centers
指導教授:陳永福陳永福引用關係
指導教授(外文):Chen, Yung-Fu
口試委員:陳永福陳景元陳美玲
口試委員(外文):Chen, Yung-FuChen, Jing-YuanChen, Mei-Ling
口試日期:2013-06-02
學位類別:碩士
校院名稱:中臺科技大學
系所名稱:長期整合照護與福祉服務產業碩士專班
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:2013
畢業學年度:101
語文別:中文
論文頁數:110
中文關鍵詞:護理之家住民代理家屬不施行心肺復甦術
外文關鍵詞:nursing home residentsagency familyDo-Not-Resuscitate
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背景:西元1993年,台灣65歲以上老年人口於底達到總人口的7%,約有149萬人。正式踏入高齡化社會,而人口老化已是全世界共同趨勢。護理之家住民病危CPR成功存活出院比例小於5%,因此預先選擇不施行心肺復甦術可以避免無效的新肺復甦術造成嚴重殘及與痛苦死亡,更有助於減少不必要的醫療浪費。台灣的社會風氣要預立醫囑不是一蹴可幾,而長照機構住民是較可能面臨生命末期抉擇的族群。因此,調查DNR的施行現況與現在/未來/簽署/不簽署DNR影響因子,使家屬更了解不施行心肺復甦術,以期能夠做為「安寧療護」推展的問路石,幫病人和家屬追求更高的生活品質及「善終」,減少遺憾。
目的:解護理之家住民及家屬簽署不施行心肺復甦術之現況與背景特性以及探討將來是否簽署不施行心肺復甦術之意向,找出可能影響因子作為臨床上推行簽署不施行心肺復甦術,擬定相關照護措施的參考。
方法:採橫斷式研究設計,以病歷資料獲得護理之家住民之簽署DNR現況及相關臨床資訊;家屬特質及DNR相關經驗藉由問卷形式,由護理之家工作人員在家屬來訪時,協助填寫以取得資訊,並以邏輯式回歸分析各項特質與不施行心肺復決策的相關性。
結果:本研究總收案護理之家住民122位,82位有不施行心肺復甦術決策,59.8%之決策由家屬簽暑,只有9位(7.4%)由本人簽署。使用多變項邏輯是回歸分析後,與護理之家住民不施行心肺復甦術決策相關因素有住民年齡、認知功能、家屬曾與醫師討論不施行心肺復甦術及護理之家具有不施行心肺復甦術決策。
結論:根據護理之家的護理病歷回溯及家屬問卷調查,可推測出較可能會簽署DNR的影響因素包含失智,洗腎,意識較不清楚,全癱,有氣切和巴氏量表分數低,這些臨床特性可以提供日後護理之家新住民入住時輔助辨認出可能會簽署DNR的族群。醫護人員主動提出討論與之前病危過也對DNR之決策產生相當程度的影響。因此當新住民符合上述特性但未簽署DNR時,醫護人員應主動與住民及家屬近一步討論,以達維護生命品質,避免無效醫療之美意。即使先給予DNR 與安寧緩和照護的相關衛教單張後再填寫DNR相關議題的問卷,多數家屬仍覺得目前病況尚可不考慮預立醫囑,甚至於有「突兀、不解」、「此問卷不適當,應針對有真正需求者個別說明」等意見,因此對於安寧緩和照護及預立醫囑這一塊領域,仍需更多的社會教育。

Background: 1993, Taiwan's population aged 65 and over in the bottom 7% of the total population, about 149 million people. Formally entered the aging society, and the world's aging population has been a common trend. Nursing home residents dying CPR survived to hospital discharge success ratio is less than 5%, so the pre-selected avoided not Resuscitate new pulmonary resuscitation invalid causing serious damage and pain and death, but also help to reduce unnecessary medical waste. Taiwan's social climate to advance directives not happen overnight, and long term care are more likely to face the end of life choices populations. Therefore, the investigation of DNR implemented the current situation and present / future / sign / not sign DNR impact factor, so that family members better understand not Resuscitate order to be able to be used as "hospice" promotion asked stone road, to help patients and their families to pursue a more high quality of life and "hospice" to reduce regret.
Objective: Solution of nursing home residents and their families to sign a non-Resuscitate the current status and background characteristics and to explore whether the future is not Resuscitate signed the intention to identify factors that may affect the implementation of a clinical sign not Resuscitate, intended care measures related references.
Methods: A cross-sectional study design, in order to obtain the medical records of nursing home residents to sign DNR status and relevant clinical information; family characteristics and relevant experience by DNR form of a questionnaire by the staff at the nursing home when visiting family members to help fill in order to obtain information, and logistic regression analysis of the characteristics and purposes of cardiopulmonary resuscitation decisions are not relevant.
Results: The study enrolled a total 122 nursing home residents, 82 have not Resuscitate decisions, 59.8% of the decisions signed by the families of summer, only 9 (7.4%) signed by me. Using multivariate logistic regression analysis was, and nursing home residents do not Resuscitate decisions related factors residents age, cognitive function, and the family had not discussed with the physician and nursing Resuscitate the furniture has not Resuscitate decisions.
Conclusion: According to nursing home care and family medical history questionnaire back, can be inferred more likely to sign a DNR influencing factors include dementia, dialysis, consciousness is less clear, complete paralysis, with tracheostomy and Barthel index score low, these clinical characteristics can be provided in the future new residents in nursing homes assisted check signed by DNR may identify populations. Health care offered to discuss dying before the decision to DNR had also produced a considerable extent. So when the new residents comply with the above characteristics but not signed by DNR, the medical staff should take the initiative to discuss with residents and their families, taking a step forward to achieve pro-life quality, avoid ineffective health of kindness. Even the first to give DNR and palliative care-related education materials before filling out the questionnaire DNR related issues, most families still feel that the current condition still does not consider an advance directive, and even have "unexpected, puzzled," "This survey does not appropriate, should focus on the real needs of those who have individual instructions "in views, so for palliative care and advance directives that an area still needs more social education.

目錄
致謝……………………………………………………………………………I
中文摘要………………………………………………………………………II
Abstract………………………………………………………………………IV
目錄……………………………………………………………………………VI
圖目錄…………………………………………………………………………IX
表目錄…………………………………………………………………………X
第一章緒論
第一節研究背景與動機.....................................1
第二節研究目的...........................................6
第三節研究問題...........................................6
第二章文獻查證與概念架構
第一節我國機構式長期照護與護理之家........................7
第二節心肺復甦術(cardiopulmonary resuscitation, CPR)………………10
第三節 不施行心肺復甦術(do not Resuscitate, DNR)..................11
第四節護理之家住民不施行心肺復甦術的現況與影響因子………… 23
小結………………………………………………………………………29
第五節 研究架構與假設…………………………………………………29
第六節變項定義…………………………………………………………31
第七節名詞定義…………………………………………………………34
第三章研究方法
第一節研究設計…………………………………………………………36
第二節研究地點、對象及選樣…………………………………………36
第三節研究工具…………………………………………………………37
第四節研究步驟…………………………………………………………39
第五節資料分析…………………………………………………………40
第四章研究結果
第一節收案機構屬性、護理之家住民以及代理家屬之特性…………42
第二節不施行心肺復甦術………………………………………………47
第三節不施行心肺復甦術決策之相關因子……………………………48
第五章討論
第一節護理之家住民、代理家屬與機構屬性…………………………56
第二節不施行心肺復甦術………………………………………………59
第三節不施行心肺復甦術決策之相關因子…………………………62
第六章結論與建議
第一節結論……………………………………………………………67
第二節研究限制………………………………………………………68
第三節應用與建議……………………………………………………69
參考文獻……………………………………………………………………74
附錄ㄧ、安寧緩和條例……………………………………………………87
附錄二、修正安寧緩和條例條文…………………………………………91
附錄三、護理之家住民/特質與不施行心肺復甦術決策調查表…………95
附錄四、心肺復甦術衛教說明單……………………………………….97
圖目錄
圖2-5-1研究架構圖………………………………………………………31
圖3-1-1研究步驟流程圖…………………………………………………40

表目錄
表4-1-1護理之家機構特質………………………………………………42
表4-1-2護理之家住民特質………………………………………………44
續表4-1-2護理之家住民特質……………………………………………45
表4-1-3家屬特質…………………………………………………………47
表4-2-1六家護理之家特質與其住民具不施行心肺復甦術決策的比率…………48
表4-3-1機構特質在有無不施行心肺復甦術決策兩組間之分佈與差異…49
表4-3-2住民特質在有無不施行心肺復甦術兩組間分佈差異表…………51
續表4-3-2住民特質與在有無不施行心肺復甦術兩組間分佈差異………52
表4-3-3家屬特質在有無不施行心肺復甦術兩組間分佈差異……………53
表4-3-4在有無不施行心肺復甦術決策兩組間分佈有顯著差異之變項…54
表4-3-5不施行心肺復甦術決策(DNR)之相關因素(多變項分析)…………56

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