臺灣博碩士論文加值系統

「在家死亡」是多數病人期待的死亡地點，但最終是否能夠如期所願善終於熟悉的地方，仍受一些人口及疾病特性因素所影響，過去國內外對癌症病人在家死亡相關因素的研究指出年齡、性別、不同的婚姻狀況與在家死亡的相關性有不一致的定論。當病人與主要照顧者選擇在家死亡具有一致性想法，能增加病人在家死亡的機會，而主要照顧者與病人的關係是否會影響病人如願在家死亡值得進一步研究。國外已有不少針對癌症及非癌症病人在家死亡的相關性研究，當國內把安寧居家照護對象擴及非癌症病人時，需要更多研究來瞭解其影響病人在家善終的因素。因此本研究目的旨在探討接受安寧居家照護病人如願在家死亡之預測因素。
本研究為病歷回溯相關性研究設計（retrospective correlational study），以安寧居家電子病歷數據資料。南部某醫學中心安寧居家病人為方便樣本。收案條件包括:需符合安寧居家收案條件且有確實接受安寧居家照護並已死亡者、從收案到死亡均在家中接受照顧或死亡前有住院者、病歷有明確記載死亡地點、病歷有明確記載病人及家屬皆有表達期望臨終地點。收案人數共373位。資料使用SPSS22版電腦軟體分析，以卡方檢定及邏輯式回歸推論性統計進行資料分析。
結果發現安寧居家病人實際在家死亡有152人（佔40.8%），非在家死亡有221人(佔59.2%)。基本屬性對安寧居家病人選擇在家死亡的因素，年齡及性別無顯著影響(X2=0.43, p=0.513；X2=0.22, p=0.637)。婚姻狀況、癌症/非癌症、死亡前14天有無入院史及與主要照顧者關係則有顯著影響(X2=4.14, p=0.042；X2=4.93, p=0.026、X2=80.80, p=<.001、X2=6.69, p=0.010)。在邏輯式迴歸分析婚姻狀況、癌症/非癌症、死亡前14天有無入院史、與主要照顧者關係是影響安寧居家照護病人在家及非在家死亡重要預測因素。已婚病人在家死亡的倍率是未婚病人的1.54倍(95%CI=1.01-2.33，p=0.042)；癌症病人在家死亡的倍率是非癌症病人的1.62倍(95%CI=1.05-2.49，p=0.027)；死亡前14天無入院史病人在家死亡的倍率是死亡前14天有入院史病人的13.91倍(95%CI=7.13-27.12，p=<.001)；與主要照顧者是親屬關係的病人在家死亡的倍率是非親屬關係的1.89倍(95%CI=1.162-3.062， p=0.010)。
此研究結果檢視病人能如願在家死亡的預測因素包括婚姻狀況、癌症疾病、死亡前14天有住院史、親屬關係的主要照顧者，有助於提供安寧居家醫療團隊在面對病人臨終照顧的衛教指導及溝通之參考。
關鍵字:在家死亡、安寧居家療護

Predictors of death at home in Patients under hospice home care
Abstract
Dying at home is desired by most patients. However, whether patients can depart their life at a place they are familiar with is affected by various demographic and disease characteristic factors. Previous studies in Taiwan regarding factors related to dying at home among patients with cancer have not reached a consistent conclusion on the correlation between dying at home and patient age, sex, and marital status. When patients and their primary caregivers agree on dying at home, the likelihood of this occurrence may increase. Whether the relationship between patients and their primary caregivers affects the patients’ desire to death at home merits further exploration. Multiple international studies have explored the correlation of the desire to death at home among patients with and without cancer. To incorporate patients without cancer as targets of home care hospice in Taiwan, further research should be conducted to understand the factors affecting peaceful dying at home. The objective of this study is to explore the predictors of dying at home desired by patients receiving home care hospice.
The convenient sample of this retrospective correlational study consisted of electronic medical record data of patients receiving home care hospice in a medical center in southern Taiwan. The inclusion criteria were deceased patients who were eligible for home care hospice and received such care before death; patients who received home care from the moment of being included in this study to the time of death or who was hospitalized but returned home before death; patients whose medical record clearly specifies the location of death; and patients whose medical record notes the desired location of death specified by the patient and family member(s). A total of 373 patients were included. The collected data were analyzed using SPSS version 22 through inferential statistics, namely the chi-squared test and logistic regression.
The results revealed that 152 of the patients death at home (40.8%), and 221 did not (59.2%). Of the demographic variables, age and sex nonsignificantly affected patients’ choice to die at home (X2 = 0.43, p = 0.513; X2 = 0.22, p = 0.637), whereas their marital status, development of cancer, record of hospitalization 14 days prior to death, and relationship with the primary caregiver exerted a significant effect (X2 = 4.14, p = 0.042; X2 = 4.93, p = 0.026; X2 = 80.80, p = <0.001; X2 = 6.69, p = 0.010). The logistic regression revealed that marital status, development of cancer, record of hospitalization 14 days prior to death, and relationship with the primary caregiver were significant predictors of dying at home. The likelihood of married patients death at home was 1.54 times that of single patients (95% CI = 1.01–2.33, p = 0.042). The likelihood of patients with cancer dying at home was 1.62 times that of patients without cancer (95% CI = 1.05–2.49, p = 0.027). The likelihood of dying at home for patients who were not hospitalized 14 days prior to death was 13.91 times that of patients who were hospitalized (95% CI = 7.13–27.12, p = 0.001). The likelihood of dying at home for patients who were primarily cared by kinship caregivers was 1.89 times that of patients without such caregivers (95% CI = 1.162–3.062, p = 0.010).
This study examined the predictors of dying at home desired by the patients and identified the main factors as patients’ marital status, development of cancer, record of hospitalization 14 days prior to death, as well as whether patients were primarily cared by kinship caregivers. The study results could serve as a reference for medical teams of home care hospice to provide health education and communicate with patients.

Keywords: dying at home, home care hospice

目錄
第一章 緒論....................................... 1
第一節重要性及動機...................... 1
第二節研究目的.......................... 5
第三節研究問題......................... . 5
第四節名詞界定........................... 6
第二章文獻探討................................. ...8
第一節台灣安寧居家療護的現況..............8
第二節安寧居家服務與死亡地點的相關研究……10
第三節影響選擇在家死亡的相關因素..........13
第三章研究方法................................ ....21
第一節 研究架構......................... .21
第二節 研究設計...........................22
第三節 研究對象......................... .23
第四節 資料收集過程.......................24
第五節 研究工具......................... .25
第六節 資料擷取及步驟................... .26
第七節 資料處理及分析.................... 29
第八節 研究倫理考量...................... 32
第四章 結果........................................33
第一節安寧居家病人基本屬性...............33
第二節安寧居家病人實際死亡地點分布.......35
第三節基本屬性與在家死亡與否相關性.......36
第四節基本屬性與病人和主要照顧者是否一致期
待在家死亡相關性...................38
第五節基本屬性對是否在家死亡之影響.......40
第五章 討論.........................................42
第一節 安寧居家病人實際死亡地點分布.......42
第二節 基本屬性與在家死亡相關性...........46
第三節 基本屬性與病人和主要照顧者是否一致期
待在家死亡相關性...................49
第四節 安寧居家病人在家死亡與否預測因素....50
第六章 限制.........................................52
第七章 建議.........................................53
第八章 結論.........................................55

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