提問單對慢性腎臟病病人透析決策準備、及透析決策衝突與自我效能之影響

Abstract

研究背景：慢性腎臟病病人對腎臟替代治療方式準備不足，導致決定延遲，其結果可能因病情需要緊急匆忙選擇不符合個人偏好的透析方式，因而衍生日後決策後悔，此問題需要解決。 研究目的：探討提問單介入對慢性腎臟病末期病人透析決策準備、決策衝突、及決策自我效能之成效。 研究方法：採隨機控制試驗研究設計，於北市某醫學中心腎臟科門診，以慢性腎臟病第五期個案為研究對象，運用隨機分配方式將個案分為實驗組及控制組。研究開始兩組先完成基線測量(T0)後，實驗組提供提問單介入措施，控制組採取常規照護，兩組均於下次門診後進行後測(T1)，測量間隔為1~3個月，成效測量指標(工具)為透析決策準備(以跨理論模式為基礎之行為改變四個階段)、決策衝突(決策衝突量表)及決策自我效能(決策自我效能量表)。以SPSS 25.0版之廣義估計方程式(General estimating equation, GEE)分析提問單介入對透析決策準備度、決策衝突及決策自我效能之成效。 結果：計有實驗組28位、控制組26位完成前測及後測。結果發現(一)在透析決策準備度方面：實驗組準備度明顯進步(p = .033)，控制組前測與後測之透析決策準備度則無明顯差異(p = .164)；經調整干擾變項後，比較兩組前測與後測之改變差異未達統計學上意義(β=-0.06, p = .816)；(二)決策衝突：實驗組在「知情」決策衝突-分量表改善程度較控制組佳(β = -11.45, p = .035)；但兩組在整體決策衝突及其它四個分量表(價值澄清、支持性、不確定感、及有效決策)之改變均無顯著差異(p > .05)。在次族群方面，基線測量時透析決策準備處於無意圖期者，提問單介入後，實驗組在「知情」分量表降低幅度明顯較控制組多(β = -15.99, p = .026)，其餘透析決策準備階段的改變則與控制組無明顯差異；(三)決策自我效能：提問單未影響決策自我效能(β = 3.89, p = .403)；而基線時在各自不同決策準備階段之研究對象，介入前與介入後自我效能的改變量在兩組間之差異，也沒有統計學上意義(p > .05)。 結論：腎病特定提問單可以有效降低慢性腎病末期病人對於透析訊息知情方面的決策衝突，尤其是還沒真正思考透析問題之無意圖期病人。因此，提問單是有價值的工具，值得臨床推廣。然而，對於已進入意圖期及準備期者，需要更多的決策支持及個別性措施以加強透析決策準備，建議未來進一步研究。

Background: Patients with chronic kidney disease (CKD) are underprepared for renal replacement therapy, resulting in the following decision delays. As a result, they may rush to choose a dialysis modality that does not meet their personal preferences under the urgency of their medical condition, which may cause them subsequent regret. This issue needs to be addressed. Purpose: To explore the effectiveness of question prompt list (QPL) intervention on readiness for decision-making of dialysis, decisional conflict, and decisional self-efficacy in patients with CKD. Methods: A randomized controlled trial study was adopted in the nephrology clinic of a medical center in Taipei City. Subjects with CKD stage 5 status were re-cruited and randomized to the experimental and control groups. Both groups completed the baseline measurement (T0) at the beginning of the study, and then the experimental group accepted the QPL intervention while the control group received usual care. Both groups were post-tested at the next clinic visit (T1) at 1 to 3 months intervals. The out-come measures (instruments) were readiness for dialysis decision-making (four stages of behavior change based on a trans-theoretical model), decisional conflict (Decision Con-flict Scale, DCS), and decisional self-efficacy (Decision self-efficacy Scale, DSES). Using Generalized estimating equations (GEE) for SPSS version 25.0 to compare be-tween-group differences in decisional conflict and decision self-efficacy. Results: Twenty-eight participants in the experimental group and twenty-six in the control group completed the T0 and T1 measurements. The results of this study revealed that (1) Readiness for dialysis decision-making: The readiness of the experimental group improved significantly (p = .033). In contrast, the readiness of the control group for di-alysis decision-making was not significantly different between the pre-test and post-test (p = .164). However, after adjusting for confounding variables, the difference be-tween-group did not have statistical significance (β = -0.06, p = .816); (2) Decision con-flict: The experimental group showed a more significant reduction in the informed DCS subscale than the control group (β = -11.45, p = .035), but there was no statistically sig-nificant difference between the overall decisional conflict and the four subscales (values clarity, support, uncertainty, and effective decision subscales) (p > .05). In terms of sub-groups, for those who were in the pre-contemplation stage of readiness for dialysis deci-sion at baseline measurement, the experimental group showed a significantly lower in-formed DCS subscale than the control group after the QPL intervention (β = -15.99, p = .026), while the others did not differ significantly from the control group; (3) Decision Self-efficacy: The QPL did not affect decision self-efficacy (β = 3.89, p = .403), in-cluding subgroups at various stages of decision readiness at baseline. Conclusion: A nephrological QPL can effectively reduce informed decisional con-flicts for CKD patients. Especially for people who have not considered the issue of di-alysis in the precontemplation stage. The QPL is a valuable tool and is worthy of clinical promotion. However, patients in the contemplation and preparatory stages need more decision support and individualized practices to enhance dialysis decision readiness. Therefore, we recommend further study.