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完整後設資料紀錄
DC 欄位 | 值 | 語言 |
---|---|---|
dc.contributor.advisor | 胡文郁 | zh_TW |
dc.contributor.advisor | Wen-Yu Hu | en |
dc.contributor.author | 陳亭儒 | zh_TW |
dc.contributor.author | Ting-Ru Chen | en |
dc.date.accessioned | 2021-06-17T06:19:21Z | - |
dc.date.available | 2024-03-01 | - |
dc.date.copyright | 2018-10-03 | - |
dc.date.issued | 2018 | - |
dc.date.submitted | 2002-01-01 | - |
dc.identifier.citation | 參考資料
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dc.identifier.uri | http://tdr.lib.ntu.edu.tw/jspui/handle/123456789/72018 | - |
dc.description.abstract | 研究背景與目的
慢性阻塞性肺病(Chronic Obstructive Pulmonary Disease,COPD)的罹病率及死亡率在全世界有增加的趨勢,其病程進展的特性,使其發生非預期性的死亡威脅增加,突然面臨需要做維生處置決策的機會很高。已有研究顯示其於生命末期接受侵襲性及加護性醫療處置,甚至最後死於加護病房或醫院的比例均明顯偏高,影響病人本身生命最後階段的生活品質與死亡品質;這樣的情況可能不是病人本身想要的結果。因此瞭解病人對於生命末期接受維生處置的意向顯得格外重要。因此本研究目的期能藉由探討慢性阻塞性肺疾病人對於生命末期接受維生處置的意向及其影響因素,而能提供更適切的末期照護。 研究方法 本研究採橫斷性調查研究法,以立意取樣方式於北區二家醫學中心胸腔呼吸科病房及門診進行收案,研究對象為COPD病人,選樣標準為:確立診斷為COPD,第二期至第四期病人(依GOLD 分期標準):意識清楚具有溝通能力;願意參與研究並簽署同意書者。以結構性問卷,面對面訪談方式收集資料,主要測量工具有「維生處置意向量表」、「生命末期照護知識量表」、「維生處置態度量表」、和「善終概念量表」。將所得資料,以SPSS 18.0版本套裝軟體進行描述性統計、獨立樣本T檢定、單因子變異數分析、皮爾森相關分析與多元線性迴歸分析。 結果 本研究有110位COPD病人為有效樣本,平均年齡71歲(±10.0),男性居多(81.8%)、多數為已婚、教育程度國小以下,近四分之一(23.9%)居家用氧。多數病人(71位,65%)認為維生處置應由自己決定,八成(84%)病人希望生命末期能以舒適性照顧為主。整體而言,病人對於生命末期接受維生處置意向程度偏低,意向強度隨所處情境、維生處置項目的不同而有差異。在五個不同情境,接受「維生處置意向」由高而低依序為:在目前的健康狀況下(平均分數2.92,1-5分)、呼吸困難極度嚴重時(2.62)、須靠呼吸器維持維生(1.56)、無效醫療(1.44)、呈植物人狀態意向最低(1.26)。在十二項不同維生處置中,接受的意向依序為:使用抗生素、注射升壓藥物、注射急救藥物、非侵襲性面罩呼吸器、人工呼吸術、體外心臟按摩、鼻胃管灌食、心臟電擊、洗腎、氣管內插管、氣管切開術最低。對病情的瞭解程度差、自覺肺部嚴重度為中度、對維生處置抱持正面態度及認為善終較不重要者,是COPD病人「接受維生處置意向」的重要影響因子,共可解釋32.1%的變異量。 結論 目前國人預立醫療指示還不普及,臨床上COPD病人生命末期的維生治療處置決策,大多由家屬在危急情況下代做決策,然而研究發現大部分COPD 病人希望由自己決定;2019年我國「病人自主權利法」即將上路,應將COPD病人列入預立醫療照顧諮商(advance care planning)的優先對象,因COPD晚期病人急性惡化而需面臨維生處置抉擇的機會非常高。對於病情的瞭解度、自覺肺病疾病的嚴重度與維生處置的態度,有賴於醫療專業人員病情告知提供足夠且正確的訊息並適當的溝通,對病人而言,這些重要訊息會影響其接受維生處置的意向。認為善終重要的病人,接受維生處置的意向低,發展更完善且符合COPD病人末期照護的模式刻不容緩。專業人員應促進病人、家屬與專業人員間,儘早展開維生處置議題的溝通,並提供充分的訊息,透過充分持續地討論與澄清,破除病人對於維生處置態度上的迷思,以協助做出真正符合其意向的決策,提供更符合COPD病人生命末期需求之照護;也可做為推動「預立指示」政策上的參考。 | zh_TW |
dc.description.abstract | Abstract
Background and purpose The mortality and morbidity rates of Chronic Obstructive Pulmonary Disease (COPD) are increasing worldwide. There is evidence of COPD patients receiving more invasive and intensive medical care at the end-of life (EoL) and the number of those who die in intensive care units or hospitals is significantly higher than that of patients with other diseases. The trajectory characteristics of COPD which interludes of acute exacerbation make the disease dramatic decline. The incidence of unexpected threats to life has increased and patients are increasingly facing the need to make decisions about life-sustaining treatments (LSTs) that they never considered previously. Decisions for receiving LSTs at EoL not only influence patients’ quality of life at their final stage of life, but also substantially affect their quality of dying. These results may not reflect the want of COPD patients. Thus, it is necessary to understand the intentions of COPD patients regarding LSTs at EoL.This study aimed to explore the intentions of the COPD patients to receive LSTs at EoL and its related factors, which could be helpful in providing more appropriate care to them. Methods This study adopted a cross-sectional design and used purposive sampling. It was reviewed and approved by the hospital institutional review board. Participants were recruited from two hospitals at northern Taiwan. The inclusion criteria for patients were as follows: COPD patients in stage II to IV (according to the staging criteria of the Global Initiative for Chronic Obstructive Lung Disease), conscious and able to communicate, and willing to participate in the study. Data were collected through a structured questionnaires and face-to-face interviews. The contents of questionnaires included: (1) demographic data: including gender, age, education level of education, marital status, religion, and EOL care preferences, etc.; (2) scale of intention to receive LSTs; (3) COPD Assessment Tool; (4) knowledge about EoL care; (5) attitude toward LSTs; and (6) concept of good death. Statistical analyses were performed using SPSS version 20.0 for Windows. The descriptive statistics were computed for each dependent and independent variable. Pearson’s correlation coefficients were applied to test interrelationships among study variables and for multicollinearity. Variables that were significantly correlated to the scores of the intention to receive LSTs were entered into multiple regression to determine those that predicted the level of intention to receive LSTs at EoL. The two-tailed p- value of .05 was adopted as the significance standard. Results A total of 110 valid samples were obtained. The average age of COPD patients was 71 (±10.0) years, and most were married males with primary school education or lower. Almost a quarter (23.9%) was using home oxygen treatment. When the disease became terminal, most patients and families wanted a physician to inform them about it. Most patients preferred comfort care over receiving every treatment to prolong life. More than half believed that the decisions about LSTs should be made by themselves. However, almost half (45%) reported that their family members were unaware of their intentions about LSTs. Most patients did not specify a proxy.The level of willingness toward receiving LSTs of patients varied according to their situations and LST interventions. The situation factors that played a role in intentions to receive LSTs, in the descending order, were: current status, severe dyspnea greatly influencing the self-care activity, ventilator-dependence for survival, medical futility, and vegetative state. When the outcome is poor, that is, in case of medical futility or vegetative state, the intention to receive LSTs greatly reduced. Among the different LST interventions, the intentionof patients to use antibiotics was the highest, followed by injection of vasopressors and Noninvasive ventilation.. The LSTs with the lowest patient intention, in the descending order, were: tube feeding, hemodialysis, and tracheostomy. Overall, the degree of patients’ intentions to receive LSTs depended on the invasiveness and burden of the LSTs.Patients who had poor understanding of their disease, perceived moderate severity of disease, had a more positive attitude towards LSTs, and perceived the good death to be less important had more intentions to receive LSTs at EoL. These four variables explained 32.1% of total variance. Conclusions Currently, the utilization of advance directives (ADs) is still not widespread among COPD patients. COPD patients wanted make their own decisions regarding LSTs. Most did not wish to receive LSTs that potentially prolong the dying process. Clinicians should promote communication and provide an opportunity for patients to actively participate in the decision-making for their EoL care. Possible outcome and detail information about LSTs should be included in the discussion of EoL care. Adequate information on COPD patients’ condition and possible LSTs should be provided. Auxiliary media should be developed in the future to assist patients in understanding LSTs for preparing to discuss advance care planning. With adequate and continuous discussion to reveal patients' intentions to receive LSTs, a mutual shared decision can reduce the chances of COPD patients receiving inappropriate LSTs. | en |
dc.description.provenance | Made available in DSpace on 2021-06-17T06:19:21Z (GMT). No. of bitstreams: 1 ntu-107-D96426007-1.pdf: 4364077 bytes, checksum: 3818879f2973e7459617446ceab1a3b3 (MD5) Previous issue date: 2018 | en |
dc.description.tableofcontents | 目錄
誌謝......................................................Ⅰ 中文摘要…………………………………………………………………ⅰ 英文摘要…………………………………………………………………ⅲ 目錄 ⅵ 表目錄 ⅺ 圖目錄 ........ⅻ 第一章 緒論 1 第一節 研究背景與重要性 1 一、慢性阻塞性肺病病人接受末期維生處置比率高 1 二、瞭解病人接受末期維生處置行為意向是提供優質末期照護的起點 2 三、揭露病人的維生處置意向有助於維護其末期照顧之自主權 3 四、目前有關的實證資料有限 5 第二節 研究目的 5 第三節 名詞解釋 6 一、慢性阻塞性肺病病人 6 二、生命末期維生處置 6 三、接受生命末期維生處置的行為意向 6 四、接受生命末期維生處置之態度(信念及評價) 6 五、重要他人之影響 7 六、生命末期照護知識 7 第二章 文獻查證 9 第一節 慢性阻塞性肺病病人之末期照護需求 9 一、慢性阻塞性肺病的病程特徵 9 二、慢性阻塞性肺病病人的末期照護需求 11 三、慢性阻塞性肺病病人末期照護的溝通 12 第二節 生命末期維生處置的概念 13 一、維生處置與無效醫療 13 二、生命末期維生處置的內容 14 三、生命末期維生處置意向的測量 15 第三節 生命末期維生處置相關之倫理議題 28 一、生命末期維生處置決策的自主性 28 二、 醫療資源分配之公平正義 30 第四節 影響對於生命末期維生處置行為意向的因素 32 一、接受末期維生處置行為意向的理論模式 32 二、影響接受維生處置行為意向的因素 36 三、研究架構 44 第三章 研究方法 47 第一節 研究設計 47 第二節 研究對象 47 一、選樣標準 48 二、樣本數 48 第三節 研究工具 48 一、接受維生處置行為意向量表 48 二、接受生命末期維生處置的態度 49 三、重要參考對象之影響 49 四、生命末期照護知識 49 五、善終概念量表 50 六、呼吸困難量表與COPD評估表..................................50 第四節 研究工具信效度檢定 51 一、效度檢定 51 二、信度檢定 51 三、維生處置意向量表信效度檢驗 51 第五節 研究倫理考量 58 第六節 資料收集流程 59 一、預試階段 59 二、正式施測 59 第七節 資料分析 60 第四章 研究結果 61 第一節 研究對象的基本特性 61 一、社會人口學變項 62 二、疾病特性 63 三、生命末期照顧的相關經驗與看法................................67 第二節 各研究變項之描述性分析結果 69 一、COPD病人的末期照護知識 69 二、COPD病人的維生處置態度......................................70 三、主觀關規範(重要他人)的影響..................................72 四、COPD病人的善終概念,,,,,.....................................72 五、COPD病人對於接受維生處置的意向..............................73 第三節 基本特性與維生處置意向相關變項間之相關性 80 第四節 COPD病人基本特性、相關變項與維生處置意向之相關性 86 第五節 影響COPD病人接受維生處置的因子...........................96 一、【情境一:目前健康狀況】影響維生處置意向之因子 96 二、【情境二:呼吸困難極度嚴重】影響維生處置意向之因子 98 三、【情境三:無效醫療】影響維生處置意向之因子 99 四、【情境四:靠呼吸器維生】影響維生處置意向之因子 100 五、【情境五:植物人狀態】影響維生處置意向之因子 101 六、【整體情境】影響維生處置意向之因子 102 第五章 討論 103 第一節 COPD病人維生處置的意向 103 一、COPD病人對於生命末期照顧的經驗與想法.......................103 二、COPD病人接受維生處置的意向.................................104 三、在不同情境下,接受生命末期維生處置的意向 103 四、接受不同維生處置措施的意向 105 第二節 各研究變項與基本特性之關係 106 一、生命末期照護知識與基本特性之關係 106 二、重要他人之影響與基本特性之關係 107 三、維生處置態度與基本特性之關係 108 四、善終概念與基本特性之關係 108 第三節 接受維生處置意向的相關與重要影響因子 109 第六章 結論與建議 113 第一節 結論 113 第二節 研究貢獻 115 第三節 研究限制與建議 ………………………………………………………117 參考資料……………………………………………………………………………121 中文文獻………………………………………………………………………121 英文文獻………………………………………………………………………124 附錄…………………………………………………………………………………138 附錄一 倫理委員會臨床試驗同意證明書…………………………………138 附錄二 倫理委員會臨床試驗變更案同意證明書…………………………139 附錄三 研究倫理委員會審查同意證明書…………………………………141 附錄四 問卷內容效度專家名單……………………………………………142 附錄五 受訪同意書…………………………………………………………143 附錄六 受訪者說明及同意書………………………………………………147 附錄七 研究問卷……………………………………………………………149 表目錄 表2-1慢性阻塞性肺病晚期之指標 10 表2-2接受維生處置意願的測量工具比較表 17 表2-3善終評量工具之評析摘要表 40 表3-1測量工具之信度檢測結果 51 表3-2維生處置意向量表在各情境下之KMO及Bartlett's檢定結果 52 表3-3情境一維生處置意向量表之因素分析摘要表 53 表3-4情境一維生處置意向量表之信度分析摘要表 54 表 3-5情境二維生處置意向量表之因素分析摘要表 54 表3-6情境二維生處置意向量表之信度分析摘要表 55 表3-7情境三維生處置意向量表之因素分析摘要表 55 表3-8情境三維生處置意向量表之信度分析摘要表(n = 110) 56 表3-9情境四維生處置意向量表之因素分析摘要表(n = 110) 56 表3-10情境四維生處置意向量表之信度分析摘要表(n = 110) 57 表3-11情境五維生處置意向量表之因素分析摘要表(n = 110) 57 表3-12情境五維生處置意向量表之信度分析摘要表(n = 110) 58 表4-1研究對象之社會人口學變項 (N=110) 62 表4-2研究對象之COPD疾病狀態經驗與分期 64 表4-3 呼吸困難量表(MMRC)分布情形(n=109) 66 表4-4 CAT量表之描述性分析(n = 110) 67 表4-5研究對象對於生命末期照顧的相關經驗與想法(n=109) 68 表4-6末期照護知識之描述性分析(n = 110) 69 表4-7維生處置態度量表之描述性分析(n = 110) 71 表4-8 重要他人影響程度之描述性分析(n = 108) 72 表4-9善終概念量表之描述性分析(n = 110) 73 表4-10情境一目前健康狀況下各治療方式之描述性分析 74 表4-11情境二呼吸困難極度嚴重下各治療方式之描述性分析 75 表4-12情境三無效醫療下各治療方式之描述性分析 75 表4-13情境四靠呼吸器維生下各治療方式之描述性分析 76 表4-14情境五植物人狀態下各治療方式之描述性分析 77 表4-15 對於生命末期接受維生處置的意向 78 表4-16 基本特性在維生處置相關變項之差異性 81 表4-17 基本特性與各維生處置相關變項之相關性 85 表4-18 基本特性在維生處置意向之差異性 88 表4-19基本特性、維生處置相關變項與維生處置意向之相關性 95 表4-20情境一目前健康狀況 維生處置意向之迴歸係數摘要表 97 表4-21情境二呼吸困難極度嚴重 維生處置意向之迴歸係數摘要表 98 表4-22情境三無效醫療 維生處置意向之迴歸係數摘要表 99 表4-23情境四靠呼吸器維生 維生處置意向之迴歸係數摘要表 100 表4-24情境五:植物人狀態 維生處置意向之迴歸係數摘要表 101 表4-25影響整體維生處置意向之迴歸係數摘要表 102 圖目錄 圖2-1理性行動理論 34 圖2-2防備採納過程理論模式 35 圖2-3 研究架構 45 圖 4-1 收案流程….………………………………………………………..61 圖 4-2 不同情境下對於接受維生處置的意向……………...……….…...79 圖4-3 十二項維生處置在五個不同情境下的接受意向………...……….79 | - |
dc.language.iso | zh_TW | - |
dc.title | 慢性阻塞性肺病病人接受生命末期維生處置之行為意向與其影響因素 | zh_TW |
dc.title | Behavioral Intentions toward Life-Sustaining Treatments and Its Related Factors in Patients with Chronic Obstructive Pulmonary Disease | en |
dc.type | Thesis | - |
dc.date.schoolyear | 106-2 | - |
dc.description.degree | 博士 | - |
dc.contributor.oralexamcommittee | 邱泰源;羅美芳;陳慶餘;鄭之勛 | zh_TW |
dc.contributor.oralexamcommittee | ;;; | en |
dc.subject.keyword | 慢性阻塞性肺病,維生醫療處置,生命末期,行為意向,決策, | zh_TW |
dc.subject.keyword | Chronic Obstructive Pulmonary Disease,life-sustaining treatment,end of life,intention,decision- making, | en |
dc.relation.page | 159 | - |
dc.identifier.doi | 10.6342/NTU201804005 | - |
dc.rights.note | 未授權 | - |
dc.date.accepted | 2018-08-20 | - |
dc.contributor.author-college | 醫學院 | - |
dc.contributor.author-dept | 護理學研究所 | - |
顯示於系所單位: | 護理學系所 |
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