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研究生:黃郁晴
研究生(外文):Yu-Ching Huang
論文名稱:老人簽署「預立安寧緩和醫療意願書」之經驗探討
論文名稱(外文):Experiences of Signing " Consent Form in Palliative Care " in Elderly
指導教授:林惠如林惠如引用關係
指導教授(外文):Hung-Ru Lin
口試委員:林佩芬游麗惠
口試委員(外文):Pay-Fan LinLi-Hui Yu
口試日期:2014-01-21
學位類別:碩士
校院名稱:國立臺北護理健康大學
系所名稱:護理研究所
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:2014
畢業學年度:102
語文別:中文
論文頁數:78
中文關鍵詞:老人預立安寧緩和醫療意願書老年人醫療自主決策
外文關鍵詞:elderlyconsent form in palliative caredecision-making autonomy in elderly
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臺灣已邁入高齡化社會,根據衛生福利部統計資料,我國65歲以上老年人口之死亡比率逐年增加,如何讓老年人在走入生命末期的過程中保有尊嚴和自主醫療,是一項重要議題。本研究目的旨在探討老人簽署「預立安寧緩和醫療意願書」之經驗。採質性研究設計,深度訪談(in-depth interview)研究法,以立意取樣,於台北市某醫學中心進行收案,收案期間自2013年05月至2013年10月止。共13位受訪者,年齡介於65歲至89歲之間,平均73歲,於資料飽和後停止收案。結果發現受訪者選擇安寧緩和醫療並簽署意願書的心路歷程,共分為三階段,主題包括簽署前的醞釀、簽署的執行及簽署後的心聲,每一主題各包含數個次主題,說明老年人歷經簽署意願書前、中、後的想法及感受。受訪者從出現想要簽署的信念到實際執行簽署,均醞釀多年的歷程。受訪者認為活著要有品質,期望自己生命末期能不成為孩子的負擔、不受急救之苦、不浪費醫療資源;多數受訪者曾經歷想簽署意願書卻不清楚簽署管道的過程,當他們找到管道進行簽署後,對於完成這個思考多年的心願感到如釋重負,也為自己完成簽署的行動賦予正向意義,甚至主動表達願意參與簽署意願書的推廣工作。
透過對老人預先為自己選擇安寧緩和醫療經驗的瞭解,建議醫護人員應加強對老年人宣導選擇安寧緩和醫療之相關訊息、強化子女與老人對於末期醫療想法的溝通,及主動與老人進行末期醫療計畫之討論。此外,多數受訪者提出願意加入安寧緩和醫療推廣的行列,建議相關單位可邀請已完成簽署意願書的老人於安寧推廣活動中進行經驗分享。
本研究結果可協助臨床及社區醫護人員對於老人預先為自己選擇安寧緩和醫療的想法有更深入的了解,進而提升老年人末期醫療照護之品質。

According to statistics of the Health and Welfare Ministry, Taiwan, ROC, our coominity has become an agingsociety. The death rate of population in elderly over 65 years increases year by year. It is an important issue to let the elderly maintain the dignity and medical autonomy when they are into the end of life. The purpose of this study was to investigate the experiences of signed " consent form in palliative care " in the elderly. This study is designed as a qualitative research, by in-depth interview research methods, and purposive sampling. The participants were invited in a medical center in Taipei. A total of 13 participants, ages 65 to 89 years (mean 73 years), were recruited from May 2013 to October 2013.Our results showed that the mentality of choosing palliative care and has signed the consent form in participants, is divided into three stages, included brewing of signing consent form before, execution of signing the consent form, and described the heartfelt wishes after signing the consent form. Each stages contains a number of sub-themes , indicating of feelings of signing the consent form before, present and after. Participants appeared the beliefs to want to signed the consent form until the actual implementation, had brewing years of history. Participants believed that the quality of life should be have, expect the end of life can not become a burden on the child, do not first aid to Suffering , and not to waste the medical resources.Most of participants want to signing the consent form in the past, but unknown the pipeline. After participants found the pipeline in signing the consent form and signing done , they were feel relieved to complete the long cherished wishes. Participants completed the consent form to fill which give them the positive meaning, and even take the initiative to express willingness to sign the consent form to participate in the promotion.

Through from understand of preselecting palliative care in elderly, recommended of strengthen advocacy to choose the palliative care in relevant medical information for the elderly, and strengthen the communication between children and the elderly for end of life in medical care ideas, and take the initiative to discuss the end of life in medical care plan with elderly. In addition, the majority of participants are willing to join the ranks of those who made the promotion of palliative care. Therefore suggested the relevant units have been completed may be invited to sign a consent form for the elderly to share their experience in peace promotion activities.
The results of this study may assist in clinical and community health care workers for the elderly in advance of their choice idea for palliative care have a better understanding, and thus enhance the end of life quality in medical care for the elderly .

中文摘要…………………………………………………………………………… i
英文摘要……………………………………………………………………………ii
目次…………………………………………………………………………………iv
表次…………………………………………………………………………………vi
圖次…………………………………………………………………………………vii
第一章 緒論
第一節 研究動機與重要性…………………………………………………………1
第二節 研究目的……………………………………………………………………3
第三節 名詞解釋……………………………………………………………………3
第二章 文獻查證
第一節 「安寧緩和醫療意願」之簡介……………………………………………4
第二節 醫療自主決策………………………………………………………………15
第三節 老年人與醫療自主決策之現況……………………………………………17
第三章 研究方法
第一節 研究設計……………………………………………………………………22
第二節 研究對象之選取……………………………………………………………22
第三節 研究進行步驟………………………………………………………………23
第四節 訪談情境……………………………………………………………………23
第五節 倫裡考量……………………………………………………………………24
第六節 研究工具……………………………………………………………………25
第七節 研究資料分析………………………………………………………………25
第八節 嚴謹度………………………………………………………………………26
第四章 研究結果
第一節 受訪者基本屬性……………………………………………………………29
第二節 簽署前的醞釀………………………………………………………………31
第三節 簽署的執行…………………………………………………………………37
第四節 簽署後的心聲………………………………………………………………42
第五章 討論
第一節 簽署前的醞釀………………………………………………………………46
第三節 簽署的執行…………………………………………………………………50
第四節 簽署後的心聲………………………………………………………………52
第六章 結論、限制與建議
第一節 研究結論……………………………………………………………………55
第二節 臨床實務應用………………………………………………………………56
第三節 研究限制與未來研究建議…………………………………………………58
參考資料
中文部分……………………………………………………………………………59
外文部份……………………………………………………………………………72
附錄
附錄一 參與研究同意書………………………………………………………… 76
附錄二 個案基本資料表………………………………………………………… 77
附錄三 訪談指引………………………………………………………………… 78

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陳榮基、蘇宛農(2008).「DNR意願註記健保IC卡登錄」宣導.安寧療護雜誌,
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衛生福利部統計處(2012,6月27日).民國100年主要死因分析.取自http://www.mohw.gov.tw/cht/DOS/Statistic.aspx?f_list_no=312&fod_list_no=2622 [Ministry of Health and Welfare. (June 27, 2012) Analysis of the leading causes of death in 2011. Retrieved from http://www.mohw.gov.tw/cht/DOS/Statistic.aspx?f_list_no=312&fod_list_no=2622]
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1. 簡玉坤(2004).老年人心理壓力及因應之道:生物-心理-社會整合模式.護理雜誌,51(3),11-14。[Gen, W. K. (2004). Psychological stress and coping strategies in elderly: The bio-psycho-social model. Journal of Hospice Palliative Care,51(3), 11-14.]
2. 謝伶瑜(2011).醫護人員預立醫囑知識與相關因素之探討.長庚護理,22(2),
3. 趙可式(1997).台灣癌症末期病患對善終意義的體認.護理雜誌,44(1),48-55。[Chao, C. S. (1997). The meaning of good dying for terminally ill cancer patients in Taiwan. Journal of Nursing, 44(1), 48-55.]
4. 曾韻如、邱泰源、胡文郁、程劭儀、姚建安、陳慶餘(2005).老年癌末病人善終之評估.安寧療護雜誌,10(1),13-23。[Tseng, Y. J., Chiu, T. Y., Hu, W. Y., Cheng, S. Y., Yao, C. A. & Chen, C. Y. (2005). Good death assessment of geriatric patients with terminal cancers Taiwan Journal of Hospice Palliative Care.
5. 陳亭儒、胡文郁(2011).善終之概念分析.長庚護理,22(1),46-52。[Chen, T. Y. & Hu, W. Y. (2011). Concept analysis of good dying. Chang Gung Nursing, 22(1), 46-52.]
6. 柯文哲(2010).葉克膜(ECMO)的倫理問題.澄清醫護管理雜誌,6(2),4-7。。[Ko, W. J. (2010). Ethical issues of extracorporeal membrane oxygenation (ECMO). Cheng Ching Medical Journal, 6(2), 4-7.]
7. 胡文郁、楊嘉玲(2009).生命末期之病情告知與預立照護計畫.護理雜誌,56(1),23-28。[Hu, W. Y. & Yang, J. L. (2009). Truth telling and advance care planning. The Journal of Nursing, 56(1), 23-28.]
8. 林義鈜(2008).論醫學倫理教育.澄清醫護管理雜誌,4(4),4-7。[Lin, Y. H. (2008). Medical ethics education. Cheng Ching Medical Journal, 4(4). 4-7.]
9. 林益卿、盧建中、林盈利、徐慧娟、楊佩玉(2011).台日安寧療護發展之比較.安寧療護雜誌,16(2),133-150。[Li, L. C., Lu, C. C., Lin, Y. L., Hsu, H. C., & Yang P. Y. (2011). A comparison of hospice development in Japan and Taiwan. Taiwan Journal of Hospice Palliative Care, 16(2), 133150.]
10. 林美伶、葉莉莉、陳清惠(2009).影響病人參與醫療決策之論述.護理雜誌,53(3),83-87。[Lin, M. L., Yeh, L.L. & Chen, C. H. (2009). Patient involvement in medical decision making. The Journal of Nursing, 53(3). 83-87.]
11. 李錦虹、洪梅禎(2008).家庭功能下的病患自主權.應用倫理研究通訊,45,27-33。[Lee, G. H. & Hung, M. C. (2008). The patient's autonomy under the family functions. Newsletter for Research of Applied Ethics, 45, 27-33.]
12. 李閏華、張玉仕(2012).臺灣安寧療護社會工作發展.社區發展季刊,137,229-240。[Lee, J. H., Chang, Y. S. (2012). Hospice social work development in Taiwan. Community Development Journal Quarterly, 137, 229-240.]
13. 李素貞(2006).從海德格對科技思維的批判探討植物人安樂死之問題.弘光人文社會學報,(4),119-150。[ Lee, S. C. (2009). An inquiry into the patients in persistent vegetative state from Martin Heidegger's view of technology. Studies in the Humanities and Social Science, (4), 119-150.]
14. 李英芬、莊榮彬、方俊凱、陳榮基(2010).保障病人尊嚴,拒絕無效醫療-談安寧緩和醫療條例宣導暨意願註記健保IC卡的執行.醫療品質雜誌,4(5),17-21。[Li, I. F., Chuang, R. B., Fang, C. K.,& Chen R. C. (2010). Protection of patients' dignity, refused invalid medical-Palliative Care Act advocacy and the willingness to log in
15. 李佩珊(2003).臨終病患生活品質照護概念架構之論析.安寧療護雜誌,8(3),299-308。[Lee, P. S. (2003). Analysis of the concept of quality of life of dying persons in the context of health care. Taiwan Journal of Hospice Palliative Care, 8(3), 299-308.]