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標題: | 治癒到療護-以醫師及家屬觀點建構成功的加護病房
生命末期家庭諮詢會議 From Cure to Care –Constituting Successful Family Conference in ICU via Physician-Families’ Viewpoints |
作者: | Hou-Tai Chang 張厚台 |
指導教授: | 陳端容(Duan-Rung Chen) |
關鍵字: | 加護病房,生命末期家庭諮詢會議,限時治療,決策,維生治療, End-of-Life,Withdrawal of Life-Sustaining Treatment,Family Conference,ICU, |
出版年 : | 2018 |
學位: | 博士 |
摘要: | 研究背景: 加護病房中,病人因病況、意識不清或病況嚴重等問題,無法發揮自主原則,故需家屬或醫療代理人於病患病情發生變化或生命末期時,根據病患喜好代理病患提出要求,決定是否需繼續急救或是撤除維生系統,需透過「生命末期家庭諮詢會議(End-of-Life Family Conference, EOL FC)」與醫師正式的溝通並了解病況、預後,可作為生命末期醫屬溝通之基石。
研究目的: 安寧緩和條例於2013 年修正家屬可在病患末期傷病時選擇撤除維生治療,同時全民健保給付“EOL FC',本研究試圖從生命末期溝通的兩端-醫師與家屬的觀點,了解加護病房生命末期照護及溝通之內容方式,如何影響醫師與家屬在生命末期進行溝通之內容及建議決策選項, 建立成功的生命末期家庭諮詢會議達成醫屬共識,使家屬做出正確無憾的決策。 研究方法: 首先針對專職於加護病房具生命末期家庭諮詢會議執行經驗之醫師進行半結構式深度訪談,經由其訪談內容得出醫師對於生命末期病患照護內容、溝通內容、及其認知為成功的「生命末期家庭諮詢會議」必要條件,第二部分經由醫師推薦,訪談參加過「生命末期家庭諮詢會議」家屬,且具決策生命末期撤除或不予維生治療經驗者,了解家屬面臨病患危急狀況之應對模式,如何做出撤除/不予維生治療之決策,了解生命末期的照護需求。 研究結果: 訪談醫師共31 位,就職於醫學中心25 位(80.6%),北部:中部:南部:東部=17:4:3:1,區域醫院醫師6 位,北部:中部: 東部=3:1:2,醫師認為判定病患進入末期最為困難,加護病房的生命末期定義不適合以預期存活時間多久來判定,而是以多重器官衰竭,經過限時治療(Time-Limited Trial) 無效,以病人最大利益為考量來判定。醫師認為的成功的「生命末期家庭諮詢會議」必要條件為達成共識。90%的醫師認為意識嚴重損傷的病患,活著很沒尊嚴,更偏向末期認定,而針對生命末 期可執行的限制維生醫療,是否會因為”滑坡謬誤”導致濫用這個議題,受訪醫師意見分歧,顯示限制維生醫療之處置仍需嚴格監控。訪談家屬共9 位,其中8 位家屬決策撤除維生治療,一位家屬決策不予維生治療,整段決策過程分為幾個階段- 家屬應對病患危急程度急慢性疾病有別、從治癒到照護轉折點、有壓力的決策過程、決策後需要珍惜時間進行家族的再連結及與病人道別、執行撤除維生治療過程後家屬重視的是以舒適為導向的治療(Comfort) 、需要陪伴病人直到最後一刻(Accompany)、需要減輕決策帶來的心理負擔(Relief)、並希望能有夠有溫度的支持(Empathetic support),九位家屬對於病患在加護病房生命末期時接受的照護及撤除 維生治療的決策感到滿意且無憾。 結論: 要達成”Shared decision-making “的目標,需要醫師與家屬共同努力,本研究透過訪談加護病房醫師及具決策生命末期照護方式之家屬,發現醫師及家屬皆認為“生命末期的家庭諮詢會議'在決策病患生命末期的照護很重要,醫療主管機構在認知時機、會議內容及執行面的標準化、制度化能夠更積極,家屬的準備度在溝通後比醫療團隊想像中的更好更早,本研究找出影響此類會議成功與否的進行模式以及加護病房生命末期照護的影響因子,希望做為以後研究者及新進醫師治療的指引,做為改進重症病患生命末期的照護品質的基石。 Abstract Background: Many patients admitted to intensive care unit (ICU) with unknown preferences, and families were required to act as surrogate to make the decision to continue or withdraw life-sustaining treatment (LST). Families communicated with physicians about the goals of care and prognosis in end-of-life family conferences (EOLFC) worked as a cornerstone of end-of-life communication. Little evidence in the past articulated the successful EOLFC and well described how families made the end-of-life decision. Objectives: The objective of this study was to constitute the successful end-of-life family conference through the lens of physician and families’ viewpoints, and explore the process of how families experienced during end-of-life care and how they made the end-of-life decision. Material and methods: Semi-structured interview were conducted to ICU physicians and families who had participated in EOLFC and had experiences of decision to withdraw/withhold life-sustaining treatment. The verbatim was analyzed with MAXQDA Ver12 and word cloud generator - Wordclouds. Results: Thirty-one ICU physicians and nine families were enrolled into the study with purposive sampling. The average age of physicians is 43.3 y/o and the average age of families is 48.2 y/o. Twenty-one physicians (67.6%) have 6 years’ or more experience in ICU. For non-cancer and critically-ill patients, physicians felt difficult to identify the status when patients approached end of life period. Most physicians supposed ICU end-of-life as multi-organ failure which responded poorly to time-limited trial and should be managed according to patients’ best interests. Ninety percent physicians considered poor dignity in patients with severely impaired consciousness, and prone to withdraw life sustaining treatment in such group. The opinion was more diverse in physicians who were asked about“Limited intensive care is a “slippery slope” that will lead to abuses”, which hint audit about LST is indicated. Eight families had experiences to withdraw LST after EOLFC. The process of decision to withdraw LST included stages as follows: Different families’ readiness, Turning points from cure to care, Stressed decision-making, Compassionate silence、connected、Reassurance and closure, and continued CARE ( Comfort, Accompany, Relief and empathetic support ). All families considered EOLFC important for them to make end-of-life decision and were satisfied about the process of LST withdrawal. Conclusions: In our study, we found EOLFC important to guide end-of-life decision in ICU. In addition to the structure and process of EOLFC, physicians and families should communicate well to achieve “shared decision-making” about end-of-life care. |
URI: | http://tdr.lib.ntu.edu.tw/jspui/handle/123456789/70453 |
DOI: | 10.6342/NTU201802873 |
全文授權: | 有償授權 |
顯示於系所單位: | 健康政策與管理研究所 |
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