病情資訊提供對於預後極差的神經重症病患家屬之影響

Abstract

在神經外科醫師處理嚴重頭部外傷與腦出血的原則之中，對於某些在術前或是送達醫院便呈現深度昏迷的年長病患[昏迷指數,GCS[Glasgow Coma Scale] 小於6分且年齡大於60歲]，其臨床決策大多較偏向建議家屬不要再進行積極的手術介入處理，乃因為根據臨床證據導向醫學，其疾病癒後有極高的可能會呈現植物人狀態或是腦死。雖然有成功恢復意識的案例，但其機率仍低。進一步說，在臨床上不乏發現進入長期照護後，家屬才發現醫療花費龐大、病人喪失尊嚴、家屬需要犧牲生活品質等等問題，不是在決定接受積極手術介入救治的當下可以想像的。 本次研究，旨在探討醫療團隊在作病情解釋時，對預後狀態說明清晰程度，是否影響病患家屬在醫療決策上的態度。在2010年8月至11月期間，使用的研究工具為提供資訊詳細程度不同的兩組情境式問卷[A卷提供一般的病情解釋內容；B卷提供較詳細的病人預後與後續照護資訊]，對台灣大學附設醫院外科加護病房及手術室外等候的352位家屬發出問卷。問卷發放使用亂數分配。最終回收290份問卷[A/B卷：144/146]，問卷回收率約82%。兩組家屬的一般資料在統計後，並無明顯統計學差異。在人口學特質方面，本研究發現，在面對神經重症且預後不佳的狀況下，較傾向於進行開顱手術而非內科治療的病患家屬之人口學特質包括：男性、年齡小於50歲者，與非醫療背景者，其勝算比（95%信賴區間）分別為：1.93（1.04~3.58）、2.21（1.17~3.92），與2.03（1.16~2.83）；最擔心發生的病患預後狀況為「死亡」者，相較於擔心成為「昏迷或其他」狀況者，也較傾向選擇開顱手術，其勝算比（95%信賴區間）為3.07（1.64~5.50）。在病情說明方面，本研究發現若在醫療團隊提供較詳細的預後與後續照護資訊之下，病人家屬較傾向選擇內科治療，而不是積極手術介入。仔細明確的病情解說與預後說明可讓家屬有較深入的病情認識，本研究也發現，病患家屬的經濟狀況、宗教信仰與個人健康狀態，也會影響其醫療決策。在面對此類家屬做病情解釋時，應站在家屬的立場出發，提供同理心與客觀的醫療資訊，必須要讓家屬充分了解積極手術介入救治的幫助與臨床限制。

In the daily practice of neurosurgical surgery, it’s not rare to encounter a patient with poor prognosis which means the patient may not be able to be alert or be capable of self caring thereafter. For a patient with traumatic brain injury, hemorrhagic intracerebral hemorrhage, or stroke, poorer prognosis is documented if the patient presented to the emergency room with Glasgow Coma Scale of less than 6 points and age older than 60 years old. Although there is possibility that the patient might be clear after intensive treatment, generally, the patient tends to be vegetative after surgical intervention such as decompressive craniectomy. Seldom neurosurgeon cares about the caregiver burden and the quality of life for the patient. The goal of the study is to differentiate whether the “detail outcome medical explanation” to the family differ the decision making of surgical intervention for the neurocritical patients with poor neurological outcome. From Aug to Dec, 2010, the study group interviewed 353 persons who is the family of patients receiving treatment in the surgical intensive care units and operation room in the National Taiwan University Hospital. By means of “Different informed vignette questionnaire”-Panel A and B, the decision making and epidemiological data were retrieved from the 290 reclaimed questionnaires [82%]. The result showed in family who are fear of patient’s death, younger aged [less than 50 years old], non-medical background, and male sex [Odds ratio （95% confident interval）: 1.93（1.04~3.58）,2.21（1.17~3.92）,2.03（1.16~2.83）, 3.07（1.64~5.50）] would tent to chose aggressive surgical intervention for the patient with poor outcome, instead of medical treatment only. Furthermore, while the family received more detailed information about the outcome and caregiver burden, they tended to treat the patient medically. We are not going to judge the value of life, but as a medical staff, we should pay great attention to make sure that the family fully understood the benefits and limits of surgical intervention before making decision for such complicated issue.