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研究生:林麗華
研究生(外文):Li-Hwa Lin
論文名稱:不施行心肺復甦術對臨終醫療使用的影響
論文名稱(外文):The effects of Do-Not-Resuscitate (DNR) on medical utilization in end-of-life care
指導教授:簡莉盈簡莉盈引用關係
指導教授(外文):Li-Yin Chien
學位類別:博士
校院名稱:國立陽明交通大學
系所名稱:公共衛生研究所
學門:醫藥衛生學門
學類:公共衛生學類
論文種類:學術論文
論文出版年:2021
畢業學年度:109
語文別:中文
論文頁數:76
中文關鍵詞:Do-Not-ResuscitateDNR簽署率DNR簽署時間臨終醫療醫療處置醫療費用
外文關鍵詞:DNRDNR signing ratetiming of DNREnd-of-life medical caremedical treatmentmedical expenses
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目的
本研究目的為探討在醫院死亡病人Do-Not-Resuscitate (DNR)簽署情形及其相關因素,並分析DNR簽署是否影響病人的臨終醫療處置及醫療費用,提供DNR政策規劃與醫療人員在臨床上執行安寧緩和醫療之參考。
方法
本研究採回溯性世代研究設計,以臺北榮民總醫院的住院死亡的病人為本研究樣本,回溯自2013年1月至2014年6月,符合收案的對象3,330人。從住院電子病歷檔查閱研究對象的基本資料檔、治療處置檔、住院處方檔和醫療費用檔,從紙本病歷查閱研究對象有無簽署DNR的文件及簽署內容,以SAS 9.4統計軟體,進行分析影響DNR簽署相關因素,其社會人口學、死亡主要診斷、主要照顧者、以及臨終醫療處置和醫療費用的差異。
結果
研究樣本中有DNR簽署者占84%,他人簽署占最多81.26%。簽署DNR病人以80歲以上、診斷為癌症、有宗教信仰、與親友同住及在加護病房死亡者較高,且具統計上顯著差異;有簽署DNR者住院天數雖較未簽署者延長3.17天 (p=0.008);簽署DNR者在最後一次住院期間比沒有DNR者少122,772.23元 (95%CI =-166,094.17- -7,9450.89; p<.0001)、死亡前7天醫療費用有DNR者比沒有DNR者少80,627.08元 (95%CI - -93,618.55- -67,635.60; p<.0001),死亡前48小時醫療費用有DNR者比沒有DNR者少53,684.45元 (95%CI =-61,070.49- -46,298.41; p<.0001)。在入院後48小時以上簽署DNR比入院後48小時內簽署者,住院天數多18.93天 (95%CI =15.89-21.98; p<.0001),住院總醫療費用多293,091.07元(95%CI = 238,926.83-347,255.31; p<.0001),死亡前7天的醫療費用多36,857.51元 (95%CI = 24,386.63- 49,328.39; p<.0001),死亡前48小時療費用多7,398.26元 (95%CI = 588.07-14,108.46; P=0.033)。DNR本人簽署者無論是住院天數、住院期間總醫療費用、死亡前七天、死亡前48小時皆比他人簽署者低。
結論
癌症病人、高齡者、有宗教信仰及住加護病房的病人DNR簽署率較高,但簽署時間都較遲。無簽署者較有簽署者醫療費用高;晚期(入院48小時後)簽署者較早期(入院48小時內)簽署DNR者,其醫療處置及費用較早期簽署者高。本人簽署比他人簽署DNR者,其醫療處置及費用皆較低,早期及本人DNR簽署是推動上可努力的方向。
Purpose
The purpose of this study was to examine the Do-Not-Resuscitate (DNR) signing status, and the factors influencing the signing, and the association between DNR signing and health care utilization as well as medical expenses among patients who died in hospitals. The study results could form a basis for DNR policy planning and implementation of hospitce and palliative medical care among medical staffs.
Methods
This was a retrospective cohort study. Data from patients who died in the Taipei Veterans General Hospital from January 2013 to June 2014 during their last hospitalization before death were obtained from the electronic medical records system, which included background characteristics file, therapeutic treatment file, prescription during hospitalization file, and medical expenses file. DNR signing document was collected from the paper medical record. The SAS 9.4 statistical software was used to analyze the data.
Results
In total, 3,330 patients were included and 84% had signed a DNR, with 81.26 % being signed by a surrogate. Patients who were 80 years of age or older, had a diagnossis of cancer, had a religion, lived with relatives, and died in the intensive care unit (ICU) were significantly more likely to have DNR signing comparing to their counterparts. Duration of the last hospitalization were 3.17 days longer (p=.008) among those who had DNR signing. Those who had DNR signing spent 122,722.23 (95%CI =-166,094.17- -7,9450.89; p<.0001), 80,627.08 (95%CI - -93,618.55- -67,635.60; p<.0001), and 53,684.45 (95%CI =-61,070.49- -46,298.41; p<.0001) NT dollars less in total medical expenses, medial expenses during 7 days before death, and 48 hours before death, respectively. Duration of the last hospitalization was 18.93 (95%CI =15.89-21.98; p<.0001) days longer among those who had their DNR signing at after 48 hours of their admission to hospital. Those who had DNR signing after 48 hours of their admission spent 293,091.07元(95%CI = 238,926.83-347,255.31; p<.0001), 36,857.51 (95%CI = 24,386.63- 49,328.39; p<.0001), and 7,398.26 (95%CI = 588.07-14,108.46; P=0.033) NT dollars less in total medical expenses, medial expenses during 7 days before death, and 48 hours before death, respectively. Those who had DNR signing by self had shorter duration of hospitalization and lower medical expenses (total, 7 days before death, 48 hours before death) than those who had DNR signing by others.
Conclusion
Those patients with a cancer diagnosis, were older, had a religion, and admitted to ICU had a higher rate of DNR signing, however, majority of their signing timing is late. Signing is related to a lower medical cose. Early signing (within 48 hours of admission) and DNR signing by self are relaed to lower medical utilization and medical expenses. Early signiing and singing by self are implementation directions for DNR promotions.
目 錄
誌謝………………………………………………………………………...................... i
中文摘要………………………………………………………………….…................…. ii
英文摘要……………………………………………..………………...…..............…….iv
目錄……………………………………………………………………….....……............... v
表目錄………………………………………………………………………….................. vii
第一章 緒論………...…………………………………………………….…................…1
第一節 研究背景………………………………………...……………................. 1
第二節 研究動機………………………………………...………………...............… 6
第三節 研究目的與問題…………………………………………....................8
第四節名詞定義………………………………………...…………………..................9
第二章 文獻查證…………………………………………….......................…11
第一節 不施行心肺復甦術(Do Not Resuscitation)的定義與起源.11
第二節 DNR簽署的相關因素…………...………………..…………............….17
第三節 DNR簽署與醫療資源使用之關係 …………....……….…........… 22
第三章 研究方法……………………………………………...…….………................27
第一節 研究設計………………………………………...……………..................…27
第二節 研究架構………………………………………...……………..................…27
第三節 研究對象………………………………………...……...................………28
第四節 研究工具………………………………………...…………..................……29
第五節 研究步驟………………………………………...……................……..……31
第六節 資料分析………………………………………...………..................………32
第七節 研究倫理………………………………………...……………..................…33
第四章 研究結果……………………………………………...…….............……..….…34
第一節 基本資料………………………………………...……………..................…34
第二節 基本資料屬性與DNR簽署意願的影響……............………...…35
第三節 DNR簽署與醫療費用的關係………………….……….…...............36
第四節 入院前和入院後簽署DNR與醫療費用的關係…….………........…38
第五節 DNR簽署與醫療處置的關係………………….…….............…...…39
第五章 討論……………………………………………...…….………...................…41
第一節 病人的社會人口學、死亡主要診斷、主要照顧者、對DNR簽署的影響………………………………………….……………...........................….…..41
第二節 DNR簽署、簽署時間的醫療費用差異………………...............45
第三節 DNR簽署、簽署時間的醫療處置差異…………….........…….....47
第六章 結論與建議……………………………………………...…….…….............….50
第一節 結論……………………………………………...…….…................…....50
第二節 研究限制…………………………………………….....................…….52
第三節 建議……………………………………………...…….………..................…52
參考文獻………………………………………………………………........................66
附錄 同意臨床試驗證明書………………...………………...........……………...76
表目錄
表 1.資料分析方法……….……………………………………….............…………...32
表 2.基本資料……..……………………………………………………................…..54
表3.基本資料對於DNR簽署意願的影響……………….............…………..56
表4.DNR有無的住院天數、醫療費用………………...............…………..57
表 5. DNR簽署者與醫療費用………………..……………………............…………58
表6.本人DNR簽署內容與醫療費用…..………………….…………..............58
表7.DNR簽署時間與醫療費用………………………….....................….59
表8.入院後DNR簽署時間與醫療費用……………...............……………..59
表9.DNR有無對於醫療費用的影響………………….…................……..60
表10. DNR簽署者對於醫療費用的影響 ……...……………………...….....….60
表11.本人DNR簽署內容對於醫療費用的影響………………...........…………61
表12. DNR簽署時間對於醫療費用的影響………………...……….......……...61
表13. DNR簽署對於醫療利用的影響:入院後簽DNR的人其簽署時間.. 62
表14. DNR有無與醫療處置……………………………………...… ……............….63
表15. DNR簽署時間與醫療處置…………………….………...............……………63
表16. DNR入院後簽署與醫療處置………………………….............……………….64
表17. DNR簽署者與醫療處置……………………………………..............…….… .64
表18.本人DNR簽署項目與醫療處置…………………………….............……...65
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