加護病房護理師對生命末期病人實務照護之看法及影響因素：以撤除維生醫療為例

Abstract

研究背景：隨著醫療科技不斷進步，加護病房大量使用維生醫療來延長病人生命，但每年仍有20%的病人最終於加護病房往生。近年來重症單位的末期照護也開始受到重視，而末期照護需考量病人、家屬及醫療團隊的三方意見，增加其複雜性。由國內外研究中發現，護理師對於末期實務照護看法與臨床指引不一致，也較少針對華人社會，有關儒家思想孝道的觀點做進一步探討，因此期能藉此研究了解我國護理師對於加護病房病人末期照護之看法及影響因素。 研究目的：本研究旨在探討加護病房護理師對於已決定不予或撤除維生醫療的重症病人需接受的末期實務照護之看法及影響因素（包含決策過程的態度、參與末期決策及家庭會議的經驗）。 研究方法：本研究採橫斷式相關性研究設計，研究對象為直接參與病人照護之護理師，包括護理長、專科護理師及臨床護理師，收案期間為2020年6月1日至6月30日，收案場所為北部某醫學中心之加護病房。研究工具採英國學者Latour所設計之問卷VENICE（Views of European Nurses in Intensive Care on End-of-life-care），問卷包含決策過程的態度、參與末期決策的經驗及末期實務照護的看法。 研究結果：共有211位護理師參與本研究，結果發現在末期實務照護的看法上，大部分的護理師都認為應該提供有效的疼痛緩解（99.1%）、宗教及靈性支持（97.2%）及具有隱私的單人病室（88.1%），此與臨床指引看法較一致的。部分護理師認為不應該執行以下處置: 繼續接受靜脈輸液來保持水分（42.7%）及使用呼吸器的病人氧氣濃度應該調降到大氣濃度（21.9%）。超過一半(64.5%)的護理師認為應該繼續給予營養支持，此與臨床指引看法較不同。影響末期實務經驗的因素包含，醫護人員的宗教觀點、護理師考量加護病房佔床率、生命末期決策的討論時機、主動參與生命末期討論的積極度等因素有關。 結論：為使病人能有更好的生命末期照護品質，達到良好的善終，建議未來可多著墨於護理師看法與臨床指引差異較大之臨床討論，如是否提供人工營養與水分、調降氧氣濃度等，以達成如何於加護病房提供良好的生命末期照護品質之共識和發展相關在職教育。醫療團隊能邀請護理師及早制訂家庭會議流程機制，儘早啟動家庭會議，提升末期照護決策之討論效率。

Background: The life-sustaining treatments are commonly provided to extend the terminally ill patient’s life at the intensive care unit (ICU). However, about 20% of the patients died at the ICU. Providing the end-of-life care is influenced by the opinions of the patients’ family and the medical professionals. Therefore, end-of-life care might not be consistent with clinical guidelines. The studies in western society found that nurses have different views of good end-of-life care. However, there is a lack of study in Chinese society to understand nurses’ view of a good end-of-life care for the terminally ill patients. Objectives: This study aimed to explore nurses’ view about what end-of-life care should be done for the terminally ill patients in ICU and the factors associated with their views among the factors of nurses’ attitudes toward the decision-making process, the experiences of involving in decision-making process and family meetings. Design: A cross-sectional correlation design was adopted for this study. Method: The ICU nurses who are directly involved in patient’s care are invited to participate in this study. The questionnaire of VENICE (Views of European Nurses in Intensive Care on End-of-life-care) is used to collect the data. The study period was from June 1 to June 30, 2020. Results: A total of 211 nurses participated in this study and the response rate was 91.7%. The results found that most nurses agree the following should provide for the terminally ill patients: pain relief (99.1%), religious and spiritual support (97.2%) and private single room for end-of-life patient (88.1%), which were consistent with the clinical guidelines for end-of-life care. As noted, some nurse thought the following should not be provided: intravenous fluids to maintain hydration (42.7%), and oxygen concentration adjusted to the atmosphere (21.9%). Over fifty percent (64.5%) of nurses thought that nutritional support should be continued. This view is different from the guidelines. The nurse’s view of end-of-life care practice were mainly associated with they considering nurses’ and medical team’s religious views as the important factor in making decision for the terminally ill patients and their active involvement in end-of-life discussion. Conclusion: To provide a good end-of-life care for the terminally ill patients and to achieve the goal of good death, the future education needs to focus on the different views of good end-of-life care between nurses’ view and clinical guideline such as reducing artificial nutrition and hydration, oxygen concentration to room air. It is recommended to invite nurses to join in the team to have an earlier family meeting to improve the decision making process.