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完整後設資料紀錄
DC 欄位 | 值 | 語言 |
---|---|---|
dc.contributor.advisor | 陳端容(Duan-Rung Chen) | |
dc.contributor.author | Hou-Tai Chang | en |
dc.contributor.author | 張厚台 | zh_TW |
dc.date.accessioned | 2021-06-17T04:28:31Z | - |
dc.date.available | 2019-09-04 | |
dc.date.copyright | 2018-09-04 | |
dc.date.issued | 2018 | |
dc.date.submitted | 2018-08-13 | |
dc.identifier.citation | 1. IOM. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press.2001.
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dc.identifier.uri | http://tdr.lib.ntu.edu.tw/jspui/handle/123456789/70453 | - |
dc.description.abstract | 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。 | zh_TW |
dc.description.abstract | 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. | en |
dc.description.provenance | Made available in DSpace on 2021-06-17T04:28:31Z (GMT). No. of bitstreams: 1 ntu-107-D00848012-1.pdf: 1994629 bytes, checksum: a80579c9bb9129b006b27e974c785e1e (MD5) Previous issue date: 2018 | en |
dc.description.tableofcontents | 目錄
中文摘要 II 英文摘要 IV 第一章 緒論 1 第一節 問題背景 1 第二節 研究目的 4 第三節 名詞解釋 5 第二章 文獻探討 8 第一節 生命末期緩和醫療在重症醫療的重要性 8 第二節 影響生命末期照護的因素 12 第三節 生命末期家庭諮詢會議的相關研究 17 第四節 家屬與生命末期照護之研究 22 第五節 小結 24 第三章 研究設計與方法 27 第一節 研究設計 27 第二節 研究流程 33 第三節 研究架構 34 第四章 研究結果 35 第一節 受訪者資料 36 第二節 訪談內容探索-文字雲 38 第三節 訪談內容分析-醫師 39 第四節 訪談內容分析-家屬 57 第五節 家屬與醫師的對話-成功家庭諮詢會議建構要件 68 第五章 研究討論及研究限制 71 第一節 研究討論 71 第二節 研究限制 80 第六章 結論及建議 81 第一節 結論 81 第二節 研究建議 84 參考資料 127 表目錄 表1 參與醫師基本資料 88 表2 受訪家屬基本資料 89 表3 醫師訪談內容中有關生命末期內容前20名被提及的字句 90 表4 醫師訪談有關”成功的家庭諮詢會議”內容前20名被提及的字句 92 表5 家屬訪談稿中前20名被提及之字句 94 表6 醫師訪談大綱 96 表7 召開家庭會議的時機 98 表8 召開家庭會議的目的 100 表9 醫師定義之“加護病房生命末期 102 表10 醫師認知之成功的家庭會議 106 表11 ATTITUDE SCORE 108 表12 家屬訪談大綱 109 表13 決策撤除維生治療之家屬與病患預後關係表 110 表14 家屬如何面對病患生命垂危之狀況-精神壓力及對應策略 111 表15 家屬對於決策過程之認知-家屬態度的轉折點 112 表16 家屬對於決策過程之認知-決策及決策之後的需求 114 表17 家屬心中的矛盾 117 表18 醫師家屬配對表 118 表19 醫屬訪談內容歸納之有關生命末期照護之必要條件 119 圖目錄 圖1 美國胸腔學會推薦對胸腔病患進行之緩和醫療模式 85 圖2 達成共識的路徑(CONSENT PATHWAY) 86 圖3. CONCEPTUAL MODEL OF REALIZED ACCESS TO END-OF-LIFE CARE 87 圖4 加護病房生命末期文字雲圖像 91 圖5 定義成功的家庭會議關鍵字之文字雲圖 93 圖6 家屬訪談稿之文字雲圖 95 圖7 家屬於撤除維生治療過程之認知 116 圖8 成功家庭諮詢會議的整合模型 126 | |
dc.language.iso | zh-TW | |
dc.title | 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 | zh_TW |
dc.title | From Cure to Care –Constituting Successful Family Conference in ICU via Physician-Families’ Viewpoints | en |
dc.type | Thesis | |
dc.date.schoolyear | 106-2 | |
dc.description.degree | 博士 | |
dc.contributor.oralexamcommittee | 唐高駿(Gau-Jun,Tang),蔡甫昌(Fu-Chang Tsai),陽光耀(Kuang-Yao Yang),陳雅美(Ya-Mei Chen) | |
dc.subject.keyword | 加護病房,生命末期家庭諮詢會議,限時治療,決策,維生治療, | zh_TW |
dc.subject.keyword | End-of-Life,Withdrawal of Life-Sustaining Treatment,Family Conference,ICU, | en |
dc.relation.page | 137 | |
dc.identifier.doi | 10.6342/NTU201802873 | |
dc.rights.note | 有償授權 | |
dc.date.accepted | 2018-08-13 | |
dc.contributor.author-college | 公共衛生學院 | zh_TW |
dc.contributor.author-dept | 健康政策與管理研究所 | zh_TW |
顯示於系所單位: | 健康政策與管理研究所 |
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