不施行心肺復甦術(DNR)在內科加護病房氣切病人之現況分析

A Study of Do-Not-Resuscitate (DNR) among Patients with Tracheostomy in Medical Intensive Care Unit (MICU)

10.6537/TJHPC.2017.22(2).3

馬瑞菊(Jui-Chu Ma)；林佩璇(Pei-Xuan Lin)；馬瑞萍(Jui-Ping Ma)；鄭婉如(Wan-Ju Cheng)；張喬茹(Chiao-Ju Chang)；蕭嘉瑩(Chia-Ying Hsiao)；蘇珉一(Min-I Su)

不施行心肺復甦術 ； 內科加護病房 ； 氣切 ； 緩和醫療 ； DNR(Do Not Resuscitate) ； MICU(Medical Intensive Care Unit) ； Tracheostomy ； Palliative care

安寧療護雜誌

22卷2期（2017 / 07 / 01）

164 - 179

繁體中文

研究目的：探討加護病房中施行氣切病人其不施行心肺復甦術(DNR)之現況分析。材料與方法：採電子病歷回溯性調查設計，以2013 年8 月1 日至2015 年12 月31 日(共2 年5 個月)內科加護病房氣切病人進行分析。結果：氣切病人共112 位，平均年齡為71.1 歲(SD = 15.2)、所有的病人皆無健保IC 卡DNR 註記，收案之29 個月期間病人重複入院平均次數為4.3 次(SD = 3.6)、重複入ICU 平均次數為3.3 次(SD = 3.3)、醫療支出平均為417551.0 (SD = 367455.4)元。其中在本院執行氣切手術的103 位病人氣切手術同意書皆由家屬簽立，有30 位病人(佔29.1%)曾接受醫療人員DNR 意願諮商，但僅有12 位(佔11.7%)是在執行氣切手術前進行諮商，而有DNR 意願諮商組召開家庭會議的比率顯著高於未DNR 意願諮商組 (30% vs. 6.8%；P = 0.002)。在存活出院之99 位病人中平均年齡為70.8 歲(SD = 15.3)，出院時昏迷或是意識不清者有48 人(佔48.5%)，壓瘡者共31 人(27.7%)，出院時所有的病人(100%)都須臥床及依賴他人照顧且幾乎所有病人都需要24 小時氧療及呼吸器使用 (N = 95；96%)，其中又以下轉至呼吸照護病房安置者居多(N = 42；42.4%)。結論：內科加護病房氣切病人多為老年且都由家屬決定氣切手術，因此建議醫療人員對於清醒病人須尊重其醫療自主權。對於意識不清且須完全依賴照顧之病人，醫療團隊應召開家庭會議完整告知其後續照護與醫療現狀，且須宣導生命的延續不等於生活品質的確保之觀念。在醫療措施的抉擇上，應站在病人的角色切身的思考，並提供停止無效醫療之選項。

Purpose: to analyze Do-Not-Resuscitate (DNR) among patients with Tracheostomy in Medical Intensive Care Unit (MICU). Materials and Methods：a retrospective study was conducted via electronic medical records to analyze patients with tracheostomy in MICU from 1st of August, 2013 to 31st of December, 2015 (2 years and five months in total). Result: A total of 112 patients with tracheostomy were recruited with average age 71.1 years old (SD =15.2) and none of them have signed DNR agreement, with an average number of 4.3 (SD =3.6) and 3.3(SD =3.3) readmitted to hospital and ICU retrospectively during the period of study (29 months in total). There are 103 patients who have implemented tracheostomy in our hospital and all of them were with consent made by their families. Among them, 30 patients (29.1%) have received a consultation regarding tracheostomy from medical personnel in advance, but only 12 patients (11.7%) had the consultations right before surgery. The group with consultation has a significantly higher rate of discussion in their family meeting compared with the group without consultation (30% vs. 6.8%；p value = 0.002). There were 99 patients discharged from hospital with an average age 70.8 years old (SD = 15.3). Among the discharged patients, 48 patients (48.5%) were in coma or unconsciousness, 31 patients (27.7%) with pressure sores, and all of them (100%)were bedridden, dependent on others and almost all patients required 24-hour oxygen therapy and mechanical ventilation (n = 95；96%) and many of them were transferred to Respiratory care ward (RCW) (n = 42；42.4%). Conclusion: patients in MICU were mostly elder and the decision of implementing tracheostomy was made by their families. Therefore, this study suggests medical personnel should respect the medical autonomy for conscious patients. Regarding to patients who are unconscious and required full-time cares, the medical team should convene a family meeting to fully inform follow-up care of the tracheostomy, medical status and most importantly to introduce the concept that the continuation of life could not ensure patients' quality of life and to make medical decisions from the patients' point of view, providing an option to stop futile medical care.

1. 賴美玉,陳玉茹,游顯妹(2015)。接受氣切病人生活品質改變及主要照顧者認知感受之初探。源遠護理雜誌，9(3)，27-36。
   連結：
2. 立法院議案。立法院第 8 屆第 7 會期第 13 次會議議案關係文書。 104年 5 月 20 日，取自http://lci.ly.gov.tw/LyLCEW/agenda1/02/pdf/08/07/13/LCEWA01_080713_00034.pdf。
3. 安寧緩和醫療條例。中華民國九十一年十二月十一日華總一義字第09100239020 號令修正公布第 3、7 條條文。91 年 11 月 11 日，取自http://www.tho.org.tw/xms/toc/list.php?courseID=14,2000。
4. Baldwin, MR,Wunsch, H,Reyfman, PA(2013).High burden of palliative needs among older intensive care unit survivors transferred to post-acute care facilities. a single-center study.Ann Am Thorac Soc.,10(5),458-465.
5. Depuydt, P,Oeyen, S,De Smet, S(2016).Long-term outcome and health-related quality of life in difficult-to-wean patients with and without ventilator dependency at ICU discharge: a retrospective cohort study.BMC Pulm Med,16(1),133.
6. Durbin, CG, Jr(2010).Tracheostomy: why, when, and how?.Respir Care,55(8),1056-1068.
7. Engoren, MC,Arslanian-Engoren, CM(2005).Outcome after tracheostomy for respiratory failure in the elderly.J Intensive Care Med,20(2),104-110.
8. Kejner, AE,Castellanos, PF,Rosenthal, EL,Hawn, MT(2012).All- cause mortality after tracheostomy at a teriary care hospital over a 10-month period.Otolaryngol Head Neck Surg,146(6),918-922.
9. McCormick, ME,Ward, E,Roberson, DW,Shah, RK,Stachler, RJ,Brenner, MJ(2015).Life after tracheostomy: patient and family perspectives on teaching, transtions, and multidisciplinary teams.Otolaryngol Head Neck Surg,153(6),914-920.
10. Nasiłowski, J,Wachulski, M,Trznadel, W(2015).The evolution of home mechanical ventilation in Poland between 2000 and 2010.Respir Care,60(4),577-585.
11. Pan, CX,Gutierrez, C,Maw, MM(2015).Impact of palliative care program on tracheostomy utilization in a community hospital.J Palliat Med,18(12),1070-1073.
12. Vargas, M,Servillo, G,Antonelli, M(2013).Informed consent for tracheostomy procedures in Intensive Care Unit: an Italian national survey.Minerva Anestesiol,79(7),741-749.
13. 王淑珍,劉瑞芳,王淑慧,王金洲,李英俊(2013)。長期呼吸器依賴病患之主要照顧者負荷與需求探討─以南區呼吸照護病房與居家照護為例。呼吸治療雜誌，12(2)，1-15。
14. 吳清平,楊武興(2012)。台灣呼吸器長期使用概況。醫療爭議審議報導，51，1-8。
15. 林慧美,楊嘉玲,陳美妙,邱泰源,胡文郁(2011)。住院病人簽屬預立醫療指示的意願及接受宣導的意向。安寧療護雜誌，16(3)，281-295。
16. 林曉佩,陳嘉銘,許淑純,陳怡均(2013)。長期使用呼吸器患者早期氣切較晚期氣切效益探討。醫學與健康期刊，2(1)，21-29。
17. 高淑芳(2008)。探討醫生對於長期臥床老人執行氣管切開術態度之研究。崇仁學報，2，1-11。
18. 陳信儒,盧映潔(2012)。撤除心肺復甦術與病人生命權保障之爭議。台灣醫界雜誌，55(3)，9-45。
19. 蔡甫昌,方震中,陳麗光,王榮德(2012)。長期呼吸器依賴病患撤除維生治療之倫理法律議題。台灣醫學雜誌，16，156-173。
20. 衛生福利部中央健康保險署。安寧緩和醫療條例修正案。100 年 2 月 15 日，取自http://www.nhi.gov.tw/Resource/webdata/Attach_17486_2_%E5%AE%89%E5%AF%A7%E7%B7%A9%E5%92%8C%20%E9%86%AB%E7%99%82%E6%A2%9D%E4%BE%8B%E4%BF%AE%E6%AD%A3%E6%A1%88--%E7%B8%BD%E7%B5%B1%E4%BB%A4--1000000792-1.pdf。
21. 衛生福利部中央健康保險署。102 年安寧緩和醫療條例部分條文修正案。102年 1 月 14 日，取自http://www.nhi.gov.tw/Resource/webdata/22983_2_102%E5%B9%B41%E6%9C%889%E6%97%A5%E7%B8%BD%E7%B5%B1%E4%BB%A4_%E5%AE%89%E5%AF%A7%E7%B7%A9%E5%92%8C%E9%86%AB%E7%99%82%E6%A2%9D%E4%BE%8B%E9%83%A8%E5%88%86%E6%A2%9D%E6%96%87%E4%BF%AE%E6%AD%A3.pdf。
22. 衛生福利部中央健康保險署。新增八類非癌症重症末期病患也能接受安寧療護服務，並正式納入健保給付。2009年 11 月 11 日，取自http://testnhi.pstcom.com.tw/information/NewsDetail.aspx?menu=9&menu_id=544&page=38&No=808。
23. 衛生福利部統計處。93 年衛生統計動向：醫療設施、醫療人事現況與醫療服務。2008 年 7 月 9 日，取自http://www.mohw.gov.tw/cht/DOS/Statistic.aspx?f_list_no=312&fod_list_no=2158。

1. 蘇珉一,蕭嘉瑩,曾令君,馬瑞菊,林佩璇(2019)。末期維生醫療與ACP實踐－以加護病房研究為例。領導護理，20(1)，3-15。
2. 蘇珉一,蕭嘉瑩,馬瑞菊,林佩璇(2017)。如何使病人得到善終－從加護病房談起。腫瘤護理雜誌，17(增訂刊)，39-50。
3. 蘇珉一,蕭嘉瑩,鄭婉如,馬瑞菊,邱怡蓉,李孟君,李佳欣,吳珮菁(2019)。內科加護病房高齡病人臨終維生醫療處置之現況。安寧療護雜誌，23(3)，205-220。
4. 張婷(2018)。臺灣與美國預立醫療照護諮商特色之比較研究。法令月刊，69(5)，59-74。