健康識能與維生醫療偏好相關性之探討—以中台灣海線地區一般民眾為例

Abstract

研究背景 維生醫療處置的施行與否一直是臨床末期照護領域的重要課題，病人在疾病後期所接受到的醫療照顧與處置，是否符合本身的期望，攸關末期照護的品質。即將實施的病人自主權利法(以下簡稱病主法)，促使所有人提前思考，在困難的醫療情境下，自己想要接受的醫療樣貌。這些情境包括植物人、重度失智症、重度昏迷、末期病症及無法忍受的病苦狀態。民眾的健康識能會影響其預立醫療偏好的意願，也會影響醫病溝通的過程與形式。目前尚無研究調查民眾在病主法規定狀況下的醫療選擇偏好，探討健康識能及其他因素與維生醫療偏好相關性的研究亦付之闕如。 研究目的 本研究欲以問卷方式，調查民眾對生命末期價值觀的想法，並探詢在病主法指定的臨床情境中，民眾對維生醫療的選擇樣貌，同時，研究欲探討這些民眾的維生醫療偏好與健康識能及其他因素之相關性。 研究方法 研究問卷列舉常見末期照護價值觀，請受訪者一一評估其重要性；以『中文健康識能量表簡式量表』量測健康識能；以『維持生命偏好問卷』(Life Support Preferences Questionnaires, LSPQ)修正版量測民眾維生醫療偏好。修正版LSPQ包含四種臨床情境(漸凍人、重度失智症、永久植物狀態及末期癌症)及七種維生醫療處置(抗生素、鼻胃管、輸血、洗腎、膽囊炎手術、插管接呼吸器及心肺復甦術)。同時，研究收集民眾基本人口學資料。研究以方便抽樣方式在中部某區域教學醫院服務範圍收集問卷，問卷填答過程皆由填寫者獨力完成。 研究結果 有效問卷回收178份，研究發現，民眾在做維生醫療抉擇時，認為最重要的價值觀考量前三名分別為：能否恢復意識清醒、能否恢復行動自由以及是否造成經濟上負擔。女性相較於男性，對是否造成經濟上的負擔更加重視。維生醫療偏好隨臨床情境及維生醫療處置的改變而有所不同：意識狀況越差，預估存活期短時，個人越傾向拒絕維生醫療；維生醫療處置的複雜程度愈高、侵入性愈高時，個人愈傾向拒絕該處置。單變項分析發現，健康識能可能與性別、教育程度、宗教、婚姻狀態及職業有關；維生醫療偏好可能與性別、子女數目及健康識能有關。將以上單變數分析中所發現的八個變項納入羅吉斯迴歸分析後發現：與維生醫療偏好顯著相關的因素分別有性別、子女數目、教育程度、宗教、職業及健康識能。特定情境與特定處置下，女性、子女數目為兩個以上、教育程度高的受訪者，較傾向拒絕維生醫療處置。另外，控制其他因素後，重度失智症及永久植物人情境下的插管接呼吸器選擇與健康識能高低顯著相關。健康識能愈高的受試者，愈傾向選擇不施行插管接呼吸器處置，兩情境的勝算比(Odds Ratio, OR)分別為0.758，95%CI：0.59~0.972, p=0.029；0.751，95%CI：0.578~0.976, p=0.032。健康識能分數每增加一分，選擇施行呼吸器處置的機率就降低25%~30%。維生醫療選擇與其他人口學資料(如年齡、婚姻狀況、家庭收入、憂鬱情緒、生活品質、共病症及之前處置經驗)並無統計上相關性。 結論 個人的維生醫療偏好會因臨床情境、處置種類、性別、子女數目、宗教、職業的不同而有差異，健康識能高低亦與維生醫療偏好的抉擇有關，臨床醫師在與病人做維生醫療醫療決定時，應注意病人的健康識能高低與不同性別所重視的價值觀差異。健康機構應針對健康識偏低的族群發展合適的輔助工具，幫助病人在沒有溝通障礙的情況下做出完善選擇。

Background The decision of life-sustaining treatment(LST) remains an important issue in end-of-life care. Whether or not treatments conformed to a terminal patient’s expressed will deeply influence quality of end-of-life care. The Patient Autonomy Act will be launched in near future, which pushed everyone to think the goal of medical care he/she wished in certain difficult situations, including persistent vegetative state (PVS), severe dementia, deep coma, terminal diseases and intolerable suffering. Health literacy was related to willingness to sign advance directives (AD). It was also related to the type and quality of doctor-patient communication. Up to now no study depict the choices of general population in situations mentioned in Patient Autonomy Act in Taiwan. In addition, few studies investigate the associations between LST preferences and possibly related factors, including health literacy. Objective Through questionnaire, the objective of the study is to investigate the picture of end-of-life values in general population, as well as their LST choices in situations described in Patient Autonomy Act. The study also aimed at investigating the association between LST preferences and possibly related factors, including health literacy. Method In the questionnaire, we listed several end-of-life values for respondents to evaluate and rank. We used Short-form Mandarin Health Literacy Scale to measure respondents’ health literacy. We used modified Life Support Preferences Questionnaire (LSPQ) to attain respondents’ end-of-life preferences. Four situations (Amyotrophic Lateral Sclerosis, severe dementia, permanent vegetative state and terminal cancer) and 7 LST (antibiotics, nasogastric tube, blood transfusion, hemodialysis, gall bladder surgery, intubation with mechanical ventilation and cardiopulmonary resuscitation) were included in the modified LSPQ. Basic demographic data were collected in the end of the questionnaire. We used convenience sampling method to collect our data in the serving area of a regional teaching-hospital in middle Taiwan. All respondents completed the questionnaire independently without language aid. Result One hundred and seventy-eight valid questionnaires were obtained, with a response rate of 99.99%. The top-three rated end-of-life issues were：whether clear consciousness could be regained after a LST, whether mobility could be recovered after a LST and if the resulting condition after a LST caused heavy financial burden. Compared to men, women respondents put more emphasis on the issue of causing financial burden after a LST. Respondents’ preferences varied through 4 clinical situations and 7 LSTs：The worse the consciousness in clinical situations and the shorter life expectancy, the more likely a respondent to refuse a LST. Also, the more invasive a LST was, the more likely a respondent to refuse it. In univariate analysis, health literacy was significantly related to gender, education, marital status, occupations, and religion；LST preferences were significantly related to gender, number of children and health literacy. All the eight variables mentioned above were put into the multivariate logistic regression model, which revealed：LST preferences were significantly associated with gender, number of children, education level, religion, occupation and health literacy. In certain situation with specific treatment option, respondents who were woman, having more than 2 children and with higher education level were more likely to refuse a LST. As to health literacy, in situations of severe dementia and permanent vegetative state, respondents with higher health literacy score were more likely to refuse intubation with mechanical ventilation(Odds Ratio：0.758，95%CI：0.59~0.972, p=0.029；0.751，95%CI：0.578~0.976, p=0.032, respectively). The likelihood of which a respondent choose a LST decreased by 25%~30% with every score increased in health literacy scale. Other demographic data, such as age, marital status, family income, depression, quality of life, comorbidity and prior experience of a LST were not significantly associated with all LST preferences in any situations in our study. Conclusion LST preferences varied with clinical situations and type of LST. Gender, number of children, religion, occupation and health literacy were significantly related to LST preferences. Physicians should pay attentions to these factors when he/she encountered an end-of-life decision-making. Health care institutions should allocate more resources in developing effective communication tools for subjects with low health literacy, to achieve better quality in end-of-life decision making process.