加護病房肝硬化臨終病人簽署DNR同意書與醫療處置之經驗分析

The Experience of Medical Treatments and DNR Designation among Dying Patients of Liver Cirrhosis in ICU.

10.6537/TJHPC.2016.21(2).5

馬瑞菊(Jui-Chu Ma)；林佩璇(Pei-Xuan Lin)；李佳欣(Chin-Hsin Li)；蔣如富(Ju-Fu Chiang)；鄭婉如(Wan-Ju Cheng)；羅元均(Yuan-Chun Lo)；蕭嘉瑩(Chia-Ying Hsiao)；蘇珉一(Min-I Su)

加護病房 ； 肝硬化 ； 臨終病人 ； 不施行心肺復甦術 ； 延命醫療 ； ICU: Intensive Care Unit ； Liver Cirrhosis ； Dying patients ； DNR: Do-Not-Resuscitate ； Unhelpful treatment

安寧療護雜誌

21卷2期（2016 / 07 / 01）

180 - 195

繁體中文

研究目的：探討加護病房肝硬化臨終病人安寧療護之經驗。材料與方法：採電子病歷回溯性調查設計，以加護病房2013 年8 月1 日至2015 年7 月31 日(共2 年)肝硬化臨終個案進行分析。結果：臨終病人共83 位，整體DNR 簽署的比率為87.95%，較於未簽DNR 之病人死亡地點以加護病房最多，簽DNR 之病人較多返家死亡(80% vs. 56.2%；p 值=0.007)。平均簽署DNR 至死亡之時間為 5.11(SD = 9.27) 天，但是大宗多為死亡前24 小時內才簽署(58.9%)。簽署DNR 的病人有超過一半的人臨終前24 小時仍接受無效延命醫療處置，包括：52.1%血管升壓藥物、60.3%侵入性血壓生命跡象監視治療、68.5%呼吸器使用、71.2%氣管內管或氣切、95.9%抗生素治療、84.9%中心靜脈導管及69.9%抽血檢查等。而未簽署DNR 的病人其在使用血管升壓藥物、急救藥物、心外按摩、抽血檢查等醫療處置比例上較高(p ＜ 0.05)。結論：雖然加護病房肝硬化臨終病人簽署DNR比率為87.95%，但大多屬於晚期DNR(臨終前24 小時內簽署)，且其中過半病人臨終前24 小時仍然持續無效延命醫療處置。因此，若能儘早團隊介入病人與家屬緩和醫療之治療方針及維生醫療之抉擇，方能使病人免於過多無效延命醫療，並能安祥有尊嚴的離世。

Purpose: It is to explore the experiences of dying patients of Liver Cirrhosis in end-of-life care. Method: The investigation was carried out with the medical records and the analysis was proceeded with dying patients of Liver Cirrhosis from 1st August, 2013 to 31st July 2015 (2 years in total). Results: There were 83 dying patients and the signing ratio of DNR was 87.95%. Most of the patients who did not apply DNR died in ICU, whilst most of the patients applied DNR passed away at home (80% vs. 56.2%, p value=0.007). The average time from the DNR order to death is 5.11 days (SD=9.27), yet more than a half of DNR order was written within the last 24 hours (n=43, around 58.9%). Over half of the patients who had an active DNR order were still treated with ineffective unhelpful treatment within the last 24 hours (52.1% for vasopressors, 60.3% for invasive monitor of vital signs, 68.5% for using Mechanical ventilation, 71.2% for endotracheal tube or Tracheotomy, 95.9% for antibiotics treatment, 84.9% for central venous catheter and 69.9% for blood tests), whilst the patients who did not apply DNR are accounting for high proportions in using vasopressors, inotropic agent, resuscitation and blood tests (p＜0.05). Conclusion: Although 87.95% of dying patients of Liver Cirrhosis in ICU signed the DNR, most of them are later-period DNR (which was written within 24 hours before death) and more than half of the dying patients still received the ineffectively unhelpful treatments 24 hours before the death. Therefore, if the medical team gets involved in discussion of the selection of medical treatments with the patients and their family as early as possible, it can prevent the appilication of unhelpful treatments and keep the dignity of dying for those patients.

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