心臟病人對安寧緩和療護及預立醫療決定之認知、態度與簽署預立醫療決定的行為意向

Abstract

國內心臟衰竭等八大非癌，雖列入安寧緩和療護服務給付範圍，病人接受安寧緩和療護服務的比例卻不高，協助病人完成預立醫療決定是末期醫療照護的核心。由於影響機制仍缺乏完整的概念架構及預測模式，故本研究目的為，探討心臟病人對安寧緩和療護及預立醫療照護決定之認知、態度與簽署預立醫療照護決定行為意向。本研究採橫斷式調查研究設計。以北部某醫學中心的心臟內、外科門診、住院及受檢病人，年滿二十歲，確診心臟疾病為研究對象，採結構式問卷面對面訪談或自填方式收集資料。主要測量項目包括，心臟病人基本屬性、生活品質、醫療決策、安寧緩和相關知識與態度、維持生命治療之偏好、重要他人等，對「預立醫療決定」的影響。所收集之資料以SPSS 22.0 版套裝軟體進行統計分析，並建構心臟病人對接受安寧緩和療護及簽署預立醫療決定的行為意向預測模式。本研究共240 位研究對象，整體而言，心臟病人對安寧緩和有一般基本認知，但仍有七成認為安寧緩和等同安樂死的錯誤概念，以及對疾病末期心肺復甦的必要性及存活成效有過於期待的既定印象。但無論疾病結果為何，希望與家人共同獲知，透過醫病共享討論，能清楚相關醫療資訊，為自己做出醫療決策，以減輕家人負擔，不但能面對做決策時所帶來的壓力，還能獲得他人支持，有自信獲得與自身偏好相一致的照護方式。五成以上心臟病人最想要的醫療照護目標為舒適照護，不想接受任何延長生命的治療，其中高達七成以上不同意維生醫療。對預立醫療照護諮商與預立醫療決定大多持正向態度，四成以上處於「意圖期」，然而對簽署各式預立醫療決定之相關細節及內容仍有不瞭解之處，例如:認為簽署「預立安寧緩和醫療暨維生醫療抉擇意願書」，就表示個人放棄一切治癒性治療；心肺復甦術標準緊急醫療處置，總答對率為(19.6%)，以至於個人對於生命末期醫療的自主選擇權無所依循，因此仍有待再推廣與提升相關知識的必要性。路徑分析結果顯示，安寧緩和醫療之理念與知識、決策衝突，為預立醫療決定的行為意向直接預測因子；「預立醫療照護諮商」與「預立醫療決定」之態度為安寧緩和醫療之理念與知識、決策自我效能對預立醫療照護決定行為意向之中介變項。本研究希望為臨床實務應用參考及未來研究的基礎，若能介入心臟衰竭安寧緩和療護相關議題研究，將更完整提供心臟病人對安寧緩和使用度及預立醫療決定之真實狀況。

To assist patients with terminal diseases to make advance directives (ADs) is the core value of terminal care. Nevertheless, the percentage of these patients to receive hospice care remained unsatisfied despite palliative service of non-cancer diseases including heart failure had already covered by National Health Insurance. The mechanism that affected patients’ decision still lack in comprehensive concept or prediction models. In our study, we evaluate the knowledge and attitude towards hospice care and making decision beforehand in patients with cardiovascular disease, and their will to sign ADs. The study was designed as cross-section survey using structured questionnaire. Patients above 20 years of age diagnosed with cardiac disease in the Medical Center of north Taiwan were recruited by face-to-face interview or self filling of the questionnaire. The main parameters might affect ADs including patient characteristics, life quality, disease decision making policy, their possessed knowledge and like towards hospice care, their preference way to prolong living, and key care giver were evaluated. We also built a model to predict the will of patients with cardiac disease to receive hospice care and to sign ADs accordingly. All data were analyzed using software SPSS 22.0. Two hundred and forty patients were enrolled. Despite having basic knowledge among hospice care, seventy percent of them still confused hospice care with euthanasia, and held overly optimistic expectations of the effect and necessity of cardiopulmonary resuscitation (CPR) during terminal stage. Even so, most of them were willing to be informed themselves along with their family. By shared decision making (SDM), they were able to understand information related to their disease, and to make their own decision in purpose of reducing care burden of their family. Furthermore, they believed SDM would help them facing the stress making ADs, gaining support from other people, and being confident in receiving preference care. More than half preferred comfort-targeting care, not willing to receive any attempt to prolong life if no other benefit aside, with more than seventy percent of these patients agreed to withhold life-sustaining treatment. Most patients possessed positive attitude towards advanced care planning (ACP) and ADs, more than forty percent were at “ideation stage”, however many remained confused with the details and concepts related to ADs. For example, many still believed signing “Agreement of Do Not Resuscitate (DNR)” means to give up any curative therapy from now on. Only 19.6% had comprehensive knowledge of CPR standards, leading to confusions in the autonomy of terminal care, therefore required further promotion and education. Path analysis showed the idea and knowledge of hospice care one patient processed, as well as the conflict faced in decision making were direct predicting factors regarding wills to make ADs, and the attitude towards ACP and ADs served as mediator variables to the correlation between the idea and knowledge possessed, the decision-making self-efficacy, and the will to make ADs. Using our results as reference in clinical settings and foundation in future researches, we hope to intensify integration of hospice care in patients with terminal cardiac disease, providing them a more thorough and comprehensive view of real world situation in the utilization of hospice care and ADs.