探討嚴重特殊傳染性肺炎患者安寧療護之分析

Abstract

研究背景 嚴重特殊傳染性肺炎(coronavirus disease 2019)自2019年以驚人的速度席捲全球，累積至今已造成數億人染疫，並造成數百萬人死亡，患者在疫情期間可能伴隨有呼吸困難、疼痛、焦慮或社交隔離下巨大的心理壓力，在身、心、靈各方面皆是目前照護的重要面向。醫療人員應提供民眾預立醫療照護諮商以及與醫療照顧目討論，各國也針對COVID-19患者的安寧照護擬出相關指引，尤其在預期進展為重症或死亡的高風險者，在符合家屬意願下，更應考慮早期的安寧療護介入給予全人協助。然而，時至今日對於嚴重特殊傳染性肺炎確診者的安寧議題而言，錯誤的認知勢必會影響個案及家屬的臨床決定，進而延遲安寧療護啟動的時機，甚至有不適當的心肺復甦術施行，進而導致患者及其家屬無法及時得到合適的安寧緩和照顧。 研究目的 本研究之目的為探討安寧療護的介入是否會顯著影響嚴重特殊傳染性肺炎確診患者的存活期，以期能澄清嚴重特殊傳染性肺炎疫情下對於安寧療護的迷思與知識鴻溝，並且針對疫情下安寧緩和療護需求日益增加之現況，對嚴重特殊傳染性肺炎確診患者進行安寧療護需求的完整分析，包括探討人口學相關數據、身心靈等需求項目以及安寧介入方式等，以利於安寧療護之早期介入，可及早識別需求患者，並提供更全面性的評估及完善的照護計畫外，同時期勉能進一步提升民眾在安寧議題的相關識能。 研究方法 本研究在台灣北部的一家三級醫療中心進行病歷回溯性研究，蒐集2020/01-2022/10期間至急診確診為嚴重特殊傳染性肺炎患者的資料。研究對象之納入條件為20歲以上成年人共116位COVID-19確診患者，依是否進行安寧照護照會介入，進行分組為有安寧照護照會組以及無安寧照護照會組。於排除17位到院前心肺功能停止患者，將剩餘的99位COVID-19確診者，進行存活分析(N=99)。資料收集人口統計學相關變數資料、臨床數據、不施行心肺復甦術狀態、安寧療護相關變項因子、安寧療護諮詢需求以及安寧療護介入方式。結果變相包括在院期間是否使用抗生素、嗎啡或類固醇類藥物、輸血治療、確診後不施行心肺復甦術狀態、在院個案死亡率、在院心肺復甦術施行率以及存活時間分析。 研究結果 在99名患者，其中安寧療護介入組有52名患者，平均年齡為73.71歲；非安寧療護介入組則有47名患者，平均年齡為77.66歲。存活分析結果顯示在有安寧療護介入組與無安寧療護介入組兩組間並無顯著差異(p=0.9451)。此外，取前50天作存活分析，藉由時間相依共變數Cox模型(Time-dependent covariates Cox model)分析，其結果顯示並未存在與存活時間交互作用(p=0.7347)。安寧療護的介入對於嚴重特殊傳染性肺炎確診患者的存活期未有顯著影響 安寧療護諮詢需求分析，其中以社心靈需求患者居多，共50例(96.2%)；症狀治療需求者次之，共38例(73.1%)。在症狀治療需求患者中，以呼吸困難症狀為多，共26例(50%)，疼痛症狀次之，共9例(17.3%)，瞻妄患者共6例(11.5%)。安寧療護的介入方式以家醫科病房(由具安寧資格之主責照護團隊照顧)共29例(55.8%)為多，安寧共同照會共16例(30.8%)次之，轉入安寧病房照顧者則有7例(13.5%)。 結論 本研究結果可見安寧療護的介入對於嚴重特殊傳染性肺炎確診患者的存活期未有顯著影響。本研究結果也發現安寧照護以社心靈需求及症狀治療比例為高，可藉此及早識別需求患者，在安寧療護需求量日益增加但醫療資源有限的同時，期待臨床安寧療護的早期介入，能提供更全面性的評估以及更完善的照護計畫。

BACKGROUNDS The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has been spreading globally since 2019. It has infected hundreds of millions of people and caused millions of deaths. Patients may experience respiratory difficulties, pain, anxiety, and immense psychological pressure during the pandemic. Caregivers should address the physical, mental, and spiritual needs of individuals. Healthcare providers should offer pre-established medical care consultations and discussions on medical care goals to the public. Various countries have developed guidelines for palliative care for COVID-19 patients, especially for those at high risk of severe progression or death. With the consent of family members, early palliative care intervention should be considered to provide holistic assistance. However, there are still misconceptions and knowledge gaps regarding the end-of-life care issues for patients diagnosed with SARS-CoV-2 infection. Incorrect perceptions will inevitably affect clinical decisions for individuals and their families, delaying the initiation of palliative care and even leading to inappropriate resuscitation measures, resulting in patients and their families not receiving timely and appropriate palliative care. OBJECTIVE This study aimed to investigate whether palliative care intervention significantly impact the survival period of patients diagnosed with SARS-CoV-2 infection, in order to clarify the misconceptions regarding palliative care during the SARS-CoV-2 pandemic. Additionally, a comprehensive analysis of the palliative care needs of patients diagnosed with SARS-CoV-2 infection was done, including exploring demographic data, physical, psychological, and spiritual needs, as well as palliative care intervention to facilitate early intervention in palliative care, to identify patients' needs early, provide more comprehensive assessments and care plans, and further enhance public awareness of palliative care issues. METHOD This retrospective study was conducted at a tertiary medical center in Northern Taiwan, collecting data from January 2020 to October 2022 on patients diagnosed with SARS-CoV-2 infection at emergency department. The inclusion criteria for study subjects were adults aged 20 and above, including a total of 116 patients. They were grouped based on whether they received palliative care intervention, resulting in palliative care intervention group and non-palliative care intervention group. 17 patients with cardiopulmonary arrest before arrival were excluded. The remaining 99 confirmed cases of SARS-CoV-2 infected patients was then conducted with survival analysis. Retrospective data of demographic variables, clinical data, do-not-resuscitate status, palliative care-related variables, palliative care consultation needs, and palliative care intervention methods were collected. The outcomes included whether antibiotics, blood transfusion therapy, morphine or corticosteroids were used during hospitalization, the do-not-resuscitate status after diagnosis, in-hospital mortality rate, rate of cardiopulmonary resuscitation performed in-hospital, and survival time analysis. Descriptive statistics presented data in terms of frequency, percentage, mean, and standard deviation. Chi-square tests were used for categorical variables. F-test was conducted first, followed by a t-test for continuous variables. Kaplan-Meier method was used to estimate the survival rates of the palliative care intervention group and the non-palliative care intervention group, and the log-rank test was applied to evaluate the difference in survival rates between two groups. Additionally, the Cox proportional hazard model was used to study the relevant risk factors affecting survival rates, in an attempt to analyze different risk factors.

RESULTS There were 99 patients enrolled into the study, with 52 patients in the palliative care intervention group with an average age of 73.71 years, and 47 patients in the non-palliative care intervention group with an average age of 77.66 years. The survival analysis showed no significant difference between palliative care intervention group and non-palliative care intervention group. Additionally, further analysis for survival rates within the first 50 days using a time-dependent covariates Cox model indicated that there was no interaction with survival time (p=0.7347). Palliative care intervention do not have a significant impact on the survival period of COVID-19 confirmed patients. The majority of patients had psychosocial needs, totaling 50 cases (96.2%); followed by those with management for symptomatic relief needs, totaling 38 cases (73.1%). The most common symptom was difficulty breathing, with a total of 26 cases (50%). Pain symptoms came next, with a total of 9 cases (17.3%), followed by 6 cases (11.5%) of delirium patients. The most common palliative intervention method was transferal to inpatient palliative care in family medicine department, cared by primary care team with palliative care qualifications with a total of 29 cases (55.8%), followed by palliative shared care consultation with a total of 16 cases (30.8%), and 7 cases (13.5%) were transferred to the palliative care ward for inpatient care.

CONCLUSIONS The results of this study indicated that palliative care intervention do not have a significant impact on the survival period of patients diagnosed with SARS-CoV-2 infection. This study also found that palliative care focuses on psychosocial needs and management for symptomatic relief, allowing for early identification of patient needs. As the demand for palliative care increases while medical resources remain limited, it is hoped that early palliative care intervention in clinical settings can provide more comprehensive assessments and improved care plans.

KEY WORDS Palliative care, Advance care planning, End of life, COVID-19, life-sustaining treatment, Do Not Resuscitate (DNR), Survival analysis