台灣中部門診病患對生命末期使用呼吸器態度的調查

Attitude towards Utilization of Mechanical Ventilation at Terminal Stage: A Survey of Outpatients from a Hospital in Central Taiwan

10.3966/168232812014092403004

張惠雯(Hui-Wen Chang)；顏啟華(Chi-Hua Yen)；劉立凡(Li-Fan Liu)；王俊堯(Jiun-Yao Wang)；蔡崇煌(Chung-Huang Tsai)

預立意願書 ； 人工呼吸器 ； advance directives ； mechanical ventilator

台灣家庭醫學雜誌

24卷3期（2014 / 09 / 01）

136 - 147

繁體中文

背景及目的：生命末期人工呼吸器的使用屬維生醫療，在醫療團隊向家屬充份溝通，家人經審慎考慮後可決定撒除，但不知道病患個人對使用人工呼吸器的看法？本研究是中部一所醫院家醫科對門診病人研究其預立醫囑相關態度的延伸討論。方法：本研究採橫斷式研究立意抽樣方式，研究對象來自一所醫院家庭醫學科門診，共223位參與者。收案時間從2010年9月7日至2011年9月6日。應用結構式問卷一份，研究者以面訪方式進行問卷訪查。結果：人工呼吸器考慮使用預立意願書，顯著相關的因素有：年齡、教育程度、主要照顧者、宗教信仰、朋友社會支持、生活滿意度、自覺健康、曾有親友被「無意義延長生命」及曾經參與討論「不施行急救同意書」的相關經驗及曾聽過「安寧療護」相關討論。邏輯斯複迴歸分析顯示生活滿意度越好，及曾有親友被「無意義延長生命」的相關經驗的受訪者，考慮立下預立意願書決定是否使用呼吸器。自覺健康不好的受訪者，較不考慮立下預立意願書。親友曾被「無意義延長生命」的相關經驗，態度傾向不使用呼吸器。結論：本研究可提供維生醫療合法撤除前，家醫科門診病患對預立意願書的意願及態度的分析。需進一步延伸至不同特性的收案地點例如加護病房、慢性呼吸治療病房等，才能更完整評估不同病患族群之間差異性。

Background: Life-sustaining medical treatment such as mechanical ventilation might be withdrawn from a terminal patient after the prudent contemplation of the patient's family and medical staff. The attitude of patients themselves towards withholding or withdrawing mechanical ventilation, however, remains an understudied issue. A survey was accordingly conducted to study the knowledge about and attitudes toward advance directives among outpatients from family medicine department of a hospital in central Taiwan. Methods: The study was based on cross-sectional design and purposive (judgment) sampling with data collected via a structured questionnaire by interview. A total of 223 questionnaires were completed by outpatients visiting the family medicine department of a hospital in central Taiwan during the one-year period from September 7, 2010 to September 6, 2011. Results: Major findings of the study are summarized as follows: 1. In terms of personal background, variables significantly associated with the intention to sign advance directives included: age, education, caregiver, religious belief, social support from friends, life satisfaction, perceived health, experience of participating in discussions related to DNR (do-not-resuscitate) order or hospice/palliative care, and experience of seeing relatives or close friends in meaninglessly enforced prolongation of life. 2. Logistic regression analysis indicated that the intention of signing advance directives is positively associated with life satisfaction (OR = 1.09) and experience of seeing relatives or close friends in meaninglessly enforced prolongation of life (OR = 5.43). On the other hand, patients with poorer perceived health appeared to be less likely to sign advance directives (OR = 0.22). 3. Having the experience of seeing relatives or close friends in meaninglessly enforced prolongation of life emerged as a significant factor for a negative attitude towards utilizing mechanical ventilation (OR = 2.31). Conclusions: Findings of the study can be expected to help family physicians better analyze patients' attitudes towards advance directives prior to making the final decision of removing mechanical ventilation in compliance with related laws and regulations. However, more patients from different departments, notably intensive care unit and chronic respiratory ward, should be recruited to expand the sample size for more comprehensive assessments.

1. Ai, AL,Hopp, F,Shearer, M(2006).Getting affairs in order: influences of social support and religious coping on end-of-life planning among open-heart surgery patients.J Soc Work End Life Palliat Care,2,71-94.
2. Akabayashi, A,Slingsby, BT,Kai, I(2003).Perspectives on advance directives in Japanese society: A population-based questionnaire survey.BMC Med Ethics,4,E5.
3. Barrera, M,sandler, IN,Ramsay, TB(1981).Preliminary development of a scale of social support: studies on college students.Am J Community psychol,9,435-47.
4. Burke, WJ,Roccaforte, WH,Wengel, SP(1991).The short form of the Geriatric Depression Scale: a comparison with the 30-item form.J Geriatr Psychiatry Neurol,4,173-8.
5. Campbell, A(1976).Subjective measures of wellbeing.Am Psychol,31,117-24.
6. Chandramouli, S,Molyneaux, V,Angus, R,Calverley, PM,Chakrabarti, B(2011).Insights into chronic obstructive pulmonary disease patient attitudes on ventilatory support.Curr Opin Pulm Med,17,98-102.
7. Chang, YC,Yao, G,Hu, SC,Wang, JD(2015).Depression affects the scores of all facets of the WHOQOL-BREF and may mediate the effects of physical disability among community-dwelling older dults.Plos One,10,e0128356.
8. Chien, CP,Cheng, TA(1985).Depression in Taiwan: epidemiological survey utilizing CES-D.Seishin Shinkeigaku Zasshi,87,335-8.
9. D'Ath, P,Katona, P,Mullan, E,Evans, S,Katona, C(1994).Screening, detection and management of depression in elderly primary care attenders. I. The acceptability and performance of the 15-item GDS (GDS-15) and the development of a short version.Fam Pract,11,260-6.
10. Harrington, R,Loffredo, DA(2011).Insight, rumination, and self-reflection as predictors of well-being.J Psychol,145,39-57.
11. Hickman, RL, Jr,Pinto, MD(2014).Advance directives lessen the decisional burden of surrogate decision-making for the chronically critically ill.J Clin Nurs,23,756-65.
12. Hu, WY,Huang, CH,Chiu, TY,Hung, SH,Peng, JK,Chen, CY(2010).Factors that influence the participation of healthcare professionals in advance care planning for patients with terminal cancer: a nationwide survey in Taiwan.Soc Sci Med,70,1701-4.
13. Huang, YC,Huang, SJ,Ko, WJ(2010).Survey of donot-resuscitate orders in surgical intensive care units.J Formos Med Assoc,109,201-8.
14. Huang, YC,Huang, SJ,Ko, WJ(2009).Going home to die from surgical intensive care units.Intensive Care Med,35,810-5.
15. Jackson, JM,Rolnick, SJ,Asche, SE,Heinrich, RL(2009).Knowledge, attitudes, and preferences regarding advance directives among patients of a managed care organization.Am J Manag Care,15,177-86.
16. Liu, JM,Lin, WC,Chen, YM(1999).The status of the do-not-resuscitate order in Chinese clinical trial patients in a cancer centre.J Med Ethics,25,309-14.
17. Matsui, M(2007).Perspectives of elderly people on advance directives in Japan.J Nurs Scholarsh,39,172-6.
18. Menon, AS,Campbell, D,Ruskin, P,Hebel, JR(2000).Depression, hopelessness, and the desire for life-saving treatments among elderly medically ill veterans.Am J Geriatr Psychiatry,8,333-42.
19. Miller, WC,Anton, HA,Townson, AF(2008).Measurement properties of the CESD scale among individuals with spinal cord injury.Spinal Cord,46,287-92.
20. Mold, JW,Looney, SW,Viviani, NJ,Quiggins, PA(1994).Predicting the health-related values and preferences of geriatric patients.J Fam Pract,39,461-7.
21. Myers, J(2015).Improving the quality of end-of-life discussions.Curr Opin Support Palliat Care,9,72-6.
22. Rurup, ML,Pasman, HR,Goedhart, J,Deeg, DJ,Kerkhof, AJ,Onwuteaka-Philipsen, BD(2011).Understanding why older people develop a wish to die: a qualitative interview study.Crisis,32,204-16.
23. Stone, SC,Abbott, J,McClung, CD,Colwell, CB,Eckstein, M,Lowenstein, SR(2009).Paramedic knowledge, attitudes, and training in end-of-life care.Prehosp Disaster Med,24,529-34.
24. Tang, ST,Chen, CC,Tang, WR,Liu, TW(2010).Determinants of patient-family caregiver congruence on preferred place of death in Taiwan.J Pain Symptom Manage,40,235-45.
25. Tang, ST,Liu, TW,Lai, MS,Liu, LN,Chen, CH(2005).Concordance of preferences for end-of-life care between terminally ill cancer patients and their family caregivers in Taiwan.J Pain Symptom Manage,30,510-8.
26. Tang, ST,Liu, TW,Tsai, CM,Wang, CH,Chang, GC,Liu, LN(2008).Patient awareness of prognosis, patient-family caregiver congruence on the preferred place of death, and caregiving burden of families contribute to the quality of life for terminally ill cancer patients in Taiwan.Psycho-Oncology,17,1202-9.
27. Teno, JM,Nelson, HL,Lynn, J(1994).Advance care planning. Priorities for ethical and empirical research.Hastings Cent Rep,24,S32-6.
28. Thorevska, N,Tilluckdharry, L,Tickoo, S,Havasi, A,Amoateng-Adjepong, Y,Manthous, CA(2005).Patients' understanding of advance directives and cardiopulmonary resuscitation.J Crit Care,20,26-34.
29. Torke, AM,Sachs, GA,Helft, PR(2011).Timing of do-not-resuscitate orders for hospitalized older adults who require a surrogate decisionmaker.J Am Geriatr Soc,59,1326-31.
30. VandeCreek, L,Frankowski, D,Johnson, M(1995).Variables that predict interest in and the completion of living wills.J Pastoral Care,49,212-20.
31. Wiener, L,Ballard, E,Brennan, T,Battles, H,Martinez, P,Pao, M(2008).How I wish to be remembered: the use of an advance care planning document in adolescent and young adult populations.J Palliat Med,11,1309-13.

1. (2018)。探討病人自主權利法中的醫療決定內容：醫務社工師觀點。社區發展季刊，161，361-373。