探索癌症病人終止抗癌治療及接受安寧療護決策之觀點

Abstract

背景：對於不可根治的晚期癌症而言，抗癌治療因可延長生命，故仍是相當重要的。然而，對於末期、遠端轉移或復發的癌症而言，抗癌治療並不能顯著地延長存活，此時，以提升末期生命品質為目標的安寧療護，便是不可治癒癌症的首要處置選項。研究指出，多數往生者並未接受過相關服務，即便接受安寧療護者，可能在接受安寧療護後數週或甚至數日內死亡，顯示接受的時機過晚。由此可知，終止抗癌治療的決策在臨床實務上是相當困難的，而持續抗癌治療不止影響癌末病人採取積極醫療的態度，亦可能造成個體的壓力及健康體系醫療資源的耗費。 目的：從醫護團隊及病人或家屬觀點，探索癌症病人終止抗癌治療及接受安寧療護的決策。 方法：本研究採用質性方法，從臺灣東部某區域教學醫院之消化道癌症、乳癌、胸腔癌專科醫療團隊的病人與家屬，以及主責醫療團隊成員，採半結構式進行個人深度訪談，並運用NVivo 12.0 Plus質性分析軟體協助處理訪談資料與分析。 結果：本研究共計訪談主責醫療團隊成員11人，病人或家屬7人，病人診斷包括：大腸直腸癌、乳癌及肺癌。終止抗癌治療決策的因素與時機受病人年紀、不同癌別特性影響，「抗癌療效與生理健康狀態」為最主要因素，然而「主觀感受或心理因素」及「家庭社會或經濟支持」皆有相當的影響性。終止抗癌治療的決策過程包括：「主治醫師與病情告知內容與技巧」、「病人自主想法傳達」、「非醫師職類發揮輔助角色」、「尋求共識」，以及醫療端與病家端在面對相關情境各自的「因應作法」。完備的病情告知及團隊完善發揮輔助角色，有助於終止抗癌的決策。安寧療護的介入與接受，前提須醫療與病家皆接受抗癌治療為無效、無意義或死亡之必然性。選擇安寧療護的需求在於症狀處理、促進舒適、心理及靈性支持。早期介入緩和照護，有助於提升晚期癌症病人生活品質，然而現階段在急性病房推展，仍有實行的困境。 結論：本研究初步了解國內晚期癌症病人終止抗癌治療與接受安寧療護的決策，包括病人、家屬與醫療團隊的觀點。研究結果可提供於政策面、實務面推行之參考，並可作為後續研究之基礎依據。

Background: Anticancer therapy plays a big role in defeating cancer, even in already declared incurable and advanced cases. For terminal, distal metastatic or recurrent cancer patients, however, anticancer therapy cannot prolong life significantly. Hospice, therefore, is often offered as the first option under these incurable situations to improve patients’ end-of-life quality. Studies revealed that most decedents had not received any hospice service; moreover, a majority of hospice patients died within weeks, even only several days after enrolling, suggested too late to be anticipated. Accordingly, clinical decision-making concerning the withhold of anticancer therapy is difficult, and continuous anticancer therapy probably not only affect the aggressiveness of end-of-life care, but also impose considerable pressure on individuals and financially constrain their healthcare systems. Purpose: The purpose of this study is to explore process of decision-making on withholding anticancer therapy and accepting hospice care in cancer patients, from views of members in multidisciplinary care teams and patients or their families. Method: Qualitative method was adopted for this study. The semi-structured in-depth interview were separately adopted for the healthcare providers and patients or their families in gastrointestinal cancer, breast cancer and thoracic cancer multidisciplinary care team in one regional teaching hospital in eastern Taiwan. The CAQDAs, NVivo 12.0 Plus, was applied to manage and analyze the interviewed data in this qualitative research. Results: A total of 11 members in multidisciplinary care teams and 7 patients diagnosed as colorectal cancer, breast cancer, and lung cancer, or their families, were recruited in this study. The factors and timing of discontinuing anticancer treatment decisions were affected by age and different cancer characteristics. The “treatment efficacy and physical health status' were the most important factors. However, 'subjective feelings or psychological factors' and 'sociological or economic support' were both quite influential. The decision-making process for termination of anticancer treatment included: 'the content and skills of truth-telling by physicians', ' the transmission of patient's autonomous information', 'the crucial role-playing by medical assistants', 'seeking consensus', and 'the coping strategies”. Nice teamwork on truth-telling of disease and multidisciplinary care contributed to the decision on withholding anticancer remedies. While the providers of medical treatment, patients and families accepted that anticancer therapy was invalid, meaningless and the necessity of death, hospice care might be able to deliver. The reason for pursuing hospice care was to manage the problems from symptoms, to promote of comforts, and to deliver psychological and spiritual support. Early intervention of palliative care could help improving the quality of life of patients with advanced cancer. However, it is still difficult to implement in the acute ward at early stage. Conclusion: This study explored the decision-making process on withholding anticancer therapy and accepting hospice care in cancer patients with advanced cancer. The results hope to provide a useful reference in policy and practice, and a basis of research in the future.