臺灣博碩士論文加值系統

背景：近十年來國人「善終」的意識逐步抬頭，但卻常遇到病患家屬在醫院欲想談論「不施予急救復甦術」(Do Not Resuscitate,簡稱DNR)之相關議題，卻無適當的情境或機會。目前台灣生命末期的照護僅由安寧病房提供，難以達成此任務，因此必須建立以醫院為基礎之安寧照護（hospital-based palliative care）讓醫院所有單位都能讓瀕死的病患與家屬受到最好的照護。目前正在推廣居家安寧照護，照護人員仍是以醫院為基礎的訓練，比照居家照護模式由醫院的人員外展到社區進行，讓基層醫院能承接。
目的：本研究之目的在於嘗試建立以醫院為基礎之安寧緩和照護，設計安寧緩和照會需求評估表（palliative consultation care screen sheet，簡稱 PCCST），及早辨識出生命末期病患，提供初期緩和醫療照會的機會，評估病患與其家屬之需求並設定預立照護計畫。
結果：個案研究醫院收集從2010年1月1日至2011年12月30日期間住院病人之個案，其包括有效資料27,141例，採用SPSS軟體進行統計，除描述性的內容之外並以成對樣本t 檢定、卡方檢定、皮爾森相關、ROC curve分析、線性迴歸及Logistic regression進行資料分析比較。由收案起追蹤至2017年6月30日，計有3,818病例死亡(平均死亡率為14.1%)。在死亡病例中，由評分日至死亡平均存活為357日。小於等於182日(定義為生命末期)有1,876例，佔49.1%。死亡檔由ROC curve分析，資深人員評分與生命末期的切點為3.5分，資淺人員為2.5分，資深人員準確度大於資淺人員。本研究結果在預測「死亡與否」，男性較女性有較高的死亡率(odds ratio 1.39-1.40)；「年齡」odds ratio 為1.02；「分數」方面每增加1分的odds ratio 為1.26-1.29。在預測「假如死亡是否為生命末期」，「性別」上男性比較女性，odds ratio為1.24；「分數」方面每增加1分的odds ratio 為1.29。存活期的預測公式只與「評分分數」有關：存活日數=515.509+(-41.313)*總分(資深)。
結論與建議：綜合研究發現，本研究獲得以下三點結論:「緩和醫療照會評分篩檢表」各項變數與未來「是否死亡」或「假如死亡是否生命末期」具有相關性，表示這評估表適合醫院用來評估發現早期需要緩和醫療照會的病人。雖然本研究以兩組人員進行評分，由研究發現表示，資深與資淺人員評分雖有差異，但各項統計顯示準確度相同或互有優勢，表示第一線護理人員做完住院問題評估後即可，無須再由資深人員評估。由本研究所導出的公式，可預測「是否死亡」及「假如死亡是否生命末期」，可提醒臨床醫師更佳的緩和醫療照會時機。此外，緩和醫療照會可與住院中需要出院準備服務的病人連結，表示這些病人需要進入長期照護系統，可請安寧團隊及早介入，有利於社區安寧的推廣。本表也可應用於急診及居家照護團隊，以便隨時提醒醫師緩和醫療照會或介入。

In the past decades, the awareness of "good death" has gradually risen, but there were no appropriate opportunities to talk about "Do Not Resuscitate" (DNR). At present, the end-of-life care is still hospital-based in Taiwan. The current practice by hospice wards alone are not enough to achieve this task, so it is better to establish a hospital-based palliative care model. All units of a hospital should be able to take care of dying patients and their families. Even if the palliative care has been extended from the hospital to the community, care workers are still trained under hospital-based program. Regardless of causes, all end-of-life patients should receive high-quality end-of-life care. The purpose of this study was to develop an assessment tool (Palliative Consultation Care Screening Tool_ PCCST) to identify the end-of-life patients early, so that early consultation could be initiated to facilitate patient assessment and meet advanced care plan. In this study, we prospectively enrolled 27,141 hospitalized patients from January 1, 2010 to December 30, 2011. PCCST scores were assessed at admission of the patient by junior and senior staffs independently. The collected data were analyzed by SPSS software statistics, descriptive analysis, paired T test, chi-squared test and Pearson's correlation, ROC curve analysis, linear regression and Logistic regression were applied.
After a follow-up period of 6 years 6 months, a total of 3,818 enrolled cases died, and the cores from PCCST correlated well with the mortality rate. The mortality rate was 37.5% (214/570) for the patients with the score 8 points or higher. ROC curve showed the optimal cut of point for the possibility of death at score 1.5 points(area：0.701, Youden’s index (YI) =0.316). The optimal cut of point for the possibility of end-of-life at PCCST score 3.5 (area：0.660, YI=0.242). Risk factors of “the possibility of death” included male sex (odds ratio： male vs. female 1.39-1.40), age (odds ratio：1.02) and PCCST score (odds ratio 1.26-1.29). Risk factors of “the possibility of end-of-left” included sex (odds ratio： male vs. female 1.24), and PCCST score (odds ratio: 1.29). The prediction equation of life expectance when the patient died is “life expectancy (days) =515.509+ (-41.313) *score (senior staff). Despite that there were 570 cases with PCCST scores 8 points or higher, only 27 of their physician agreed with palliative consultation.
Conclusion： According to the results, the PCCST can be used as a suitable tool for end-of-life assessment, and helps identify end-of-life patients early. There were no significant differences between junior versus senior staffs. The tool is use-friendly and could be extended to emergent room or home care.

摘要 i
ABSTRACT iii
誌謝 v
目錄 vi
表目錄 x
圖目錄 xii
第一章、緒論 1
1-1 研究背景與動機 1
1-2研究目的 9
1-3名詞解釋 9
第二章、文獻探討 11
2-1善終 11
2-2生命末期(END-OF-LIFE)的定義 13
2-3不施予心肺復甦術(DNR) 17
2-4選擇DNR是病人權利 18
2-4-1給病人與家屬正確清楚的醫療訊息 19
2-4-2選擇DNR之時機 21
2-5無效醫療 21
2-5-1法律層面 23
2-5-2醫療人員對生命末期的態度及無效醫療的不確定性 23
2-5-3家屬與風俗文化因素： 23
2-5-4醫病之間缺乏時效性：永遠太晚！ 24
2-6 緩和醫療介入時機 24
2-7如何預測生命末期 26
第三章、研究方法 31
3-1 研究架構 31
3-2 研究假設 32
3-3 研究對象 32
3-4 問卷設計 33
3-5 資料編碼處理 33
3-6 信效度分析 34
3-7 資料處理方法 35
3-8 研究倫理 35
第四章、研究結果 36
4-1 收案描述 36
4-2 PAIRED T TEST 38
4-3 死亡人數統計 38
4-4 ROC CURVE 分析 43
4-4-1分析病人受評分後「是否死亡」 43
4-4-2由ROC curve針對評分後死亡病例「是否為生命末期」分析 44
4-5 卡方檢定 48
4-6 皮爾森檢定 50
4-7 迴歸預測 51
4-7-1 以羅吉斯迴歸預測評分後「是否死亡」的機率 51
4-7-1-1資淺人員 52
4-7-1-2資深人員 53
4-7-2 以邏吉斯迴歸預測如果死亡「是否生命末期」的機率 54
4-7-2-1資淺人員 54
4-7-2-2 資深人員 55
4-7-3以線性迴歸預測個案假如死亡病人的存活日數 56
4-7-3-1資淺人員 56
4-7-3-2 資深人員： 58
第五章、結論與建議 63
5-1 研究重要發現與討論 63
5-2結論 66
5-3建議 66
5-4未來研究建議 67
參考文獻 68
附錄一、不施行心肺復甦術同意書 77
附錄二、不施行維生醫療同意書 78
附錄三、預立安寧緩和醫療暨維生醫療抉擇意願書 79
附錄四、撤回預立安寧緩和醫療暨維生醫療抉擇意願聲明書 80
附錄五、醫療委任代理人委任書 81
附錄六、A QUICK GUIDE TO IDENTIFYING PATIENTS FOR SUPPOTIVE AND PALLIATIVE CARE 82
附錄七、PROPOSED COMPONENTS OF THE CRITERIA FOR SCREENING AND TRIAGING TO APPROPRIATE ALTERNATIVE CARE TOOL TO IDENTIFY END-OF-LIFE STATUS AFTER A RAPID RESPONSE CALL WHERE A DO-NOT-RESUSCITATE ORDER IS NOT IN PLACE 84
附錄八、ST MARY’S MEDICAL CENTER PALLIATIVE CARE SCREENING TOOL 86
附錄九、台大醫院雲林分院護理團隊安寧緩和照會需求評估表(初版) 87
附錄十、台大醫院雲林分院護理團隊安寧緩和照會需求評估表(正式版) 88
附錄十一、「建立以醫院為基礎安寧緩照護體系」臺大醫學院附設醫院IRB200912079R號公文 90
附錄十二、預測評分死亡率查核表 91

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