第五章 討論
第三節 建議
臨床護理人員主要在於提供病人臨床的照顧，因而忽略主要照顧 者，護理人員除了應主動關懷幫忙照顧者之外，尚需要提供協助主要照 顧者減輕其照顧負荷程度，這樣主要照顧者及臨床醫療人員才能對病人 提供最好的照顧。本研究發現主要照顧者在時間安排負荷最大，建議在 日後臨床上須適時提供協助，護理人員應積極發現主要照顧者及病人心 理狀態及經濟狀況，必要時與其他專業人員如：社工師、心理師等，提 供介入協助。
本研究使用照顧者反應評估量表（CRA）進行照顧者負荷的評估，
此評估量表適用於臨床中有壓力表現之照顧者的評估，臨床護理人員可 使用，評估及發現主要照顧者的負荷，並且提供合適措施協助。
二、護理教育方面
照顧者負荷因人不同、疾病及治療方式不而有所不同，臨床上要協 助主要照顧者緩解照顧者負荷，除了積極縣主要照顧者的問題之外，臨 床人員需要具有提供個別化的護理指導與相關措施的能力，讓主要照顧 者在照顧病人時能夠勝任。所以護理人員需要有相關醫療知識、照顧技 巧、溝通訓練和發現主要照顧者及病人心理狀態的訓練。
建議在護理教育上，要強化全人、全家照顧，以提供病人及主要照 顧者完整的生理、心理及社會照護。
三、護理研究方面
本研究結果發現病人因為疼痛及疼痛干擾、主要照顧者睡眠狀況及 主要照顧者焦慮憂鬱會影響照顧者的負荷，文獻亦指出病人疼痛干擾、
主要照顧者睡眠狀況及主要照顧者情緒會影響照顧者進而造成照顧者 健康問題，亦有文獻指出病人本身的心理狀態會影照顧者負荷，故建議 進行質性研究探討照顧者負荷。
照顧者負荷是動態的，癌症病人不論是初期診斷、治療期及治療末 期，主要照顧者的負荷會隨著病人的病情變化而改變，建議可以使用縱 貫性研究設計法瞭解主要照顧者在癌症病人不同疾病階段的照顧負荷 的變化。
參考資料 中文部分
朱立寧（2002）．癌患配偶照顧者之生活品質及其相關因素．未發表碩 士論文．長庚大學，桃園。
行政院衛生署（2005）．93 年台灣地區主要癌症死亡原因．取自2 月 1 日，2005，取自 http://www.doh.gov.tw/stiatistic/data/死因摘要/93 年 表10. xls。
李英芬（2006）‧住院腸胃道癌症病人主要照顧者負荷及相關因素‧未 發表碩士論文‧臺北醫學大學，臺北。
李梅琛、賴裕和、陳美伶、劉淑娟（2001）‧病人疼痛特質與疼痛信念 對手術後使用止痛藥物的影響‧護理雜誌，
48（1）
，49-57。邱啟潤、呂淑宜、許玉雲、朱陳宜珍、劉蘭英（1988）‧居家中風病人 之主要照顧者負荷情形及相關因素之探討‧護理雜誌，
35（1）
， 69-83。徐亞瑛、張媚、楊玉玫、黃久美（1992）‧都市型及鄉村型社區中風居 家殘病老人照顧者之附和及相關影響因素‧護理雜誌，
39（3）
， 99-106。吳聖良、胡佳杏、姚克明（1991）‧台灣地區居家照顧老人主要照顧者
吳麗玲、高淑芬、史麗珠（1998）‧腹部手術後急性疼痛定義性特徵之 臨床效度‧護理研究，
6（5）
，383-392。林秀純、徐亞瑛（1998）‧失能照顧者之照顧回饋與負荷之相關因素探 討‧長庚護理，
9（2）
，1-11。林秀純、徐亞瑛、姚開屏、吳淑瓊（1999）‧台灣北部地區失能老人家 庭照顧品質及相關因素之探討‧護理研究，
7（1）
，15-28。林梅香、顧乃平、劉仲冬、陳政友、林麗嬋（1996）．肝癌患者家屬主 要照顧者的壓力、因應行為、健康狀況及其相關因素之探討．護理 研究，
4（2）
，171-184。屈蓮、白璐、鄧光銳、王修平（1996）‧大台北地區主要照顧者之工作 負荷及對居家照顧服務之需求程度的調查‧中華雜誌，
15（4）
， 289-302。秦燕（1995）‧住院老年病患主要照顧者的壓力與需求之研究‧中華醫 務社會工作學刊，
7，1-27。
高淑芳、盧孳豔、葉淑惠、劉雪娥（1999）．探討家庭功能、社會支持 與社區殘病老人照顧者負荷之關係．護理研究，
7（2）
，172-181。高翡勵（2003）‧接受胃切除胃癌病人的症狀嚴重度、不確定感與希望 狀態之探討 ‧未發表碩士論文‧臺北醫學大學，臺北。
相關因素之探討‧公共衛生，
25（3）
，197-209。蔡佩真（1999）．死亡壓力下的家庭溝通．安寧療護雜誌，
12，26-31。
英文文獻
Aranda, S., & Hayman-White, K. (2001). Home caregivers of the person with advanced cancer: An australian perspective. Cancer Nursing,
24(4), 300-307.
Åkerstedt, T., Hume, K., Minor, D., & Waterhouse, J. (2001). The subjective meaning of good sleep an intraindividual approach using the Karolinska Sleep Diary. Cancer NursingPercep Mot Skills, 287-296.
Andrews, S. C. (2001). Caregiver Burden and Symptom Distress in People With Cancer Receiving Hospice Care. Oncology Nursing Forum, 28(9), 1469-1474.
Beckham, J. C., Burker, E. J., Rice, J. R., & Talton, MR. (1995). Patient predictors of caregiver burden, optimism, and pessimism in rheumatoid arthritis. Behavior Medicine, 20, 171-8.
Belanger, L., Morin, C. M., Langlois, F., & Ladouceur, R. (2004). Insomnia and generalized anxiety disorder: Effects of cognitive behavior therapy for gad on insomnia symptoms. Journal of Anxiety Disorders, 18(4), 561-571.
Boling, W. (2005). The health of chronically ill children: Lessons learned from assessing family caregiver quality of life. Family & Community
Health, 28(2), 176-83.
Bonica, J. (1990). Evolution and current status of pain programs. Journal of
Pain & Symptom Management, 5(6), 368-374.
Burton, L., Newsom, J., Schulz, R., Hirsch, C., & German, P. (1997).
Medicine, 26(2), 162-169.
Brazil, K., Bedard, M., Willison, K., & Hode, M. (2003). Caregiving and its impact on families of the terminally ill. Aging and Mental Health, 7(5), 376-382.
Breslau, N., Roth, T., Rosenthal, L., & Anreski, P. (1996). Sleep disturbance and psychiatric disorder : A longitudinal epidemiologic study with young adults. HealtBiological Psychiatry, 39, 411-418.
Burton, L., Newsom, J., Schulz, R., Hirsch, C., & German, P. (1997).
Preventive health behaviors among spousal caregivers. Preventive
Medicine, 26(2), 162-169.
Carpenter, J. S., & Andrykowski, M. A. (1998). Psychometric evaluation of the pittsburgh sleep quality index. Journal of Psychosomatic Research,
45(1 Spec No), 5-13.
Carter, P. A. (2002). Caregivers' descriptions of sleep changes and depressive symptoms. Oncology Nursing Forum.Online,
29(9),1277-83.
Carter, P. A., & Chang, B. L. (2000). Sleep and depression in cancer caregivers. Cancer Nursing, 23(6), 410-5.
Cohen, F. L. (1980). Postsurgical pain relief: Patients' status and nurses' medication choices. Pain, 9(2), 265-74.
Coristine, M., Crooks, B., Grunfeld, E., Stonebridge, C. & Christine, A.
(2003). Caregiving for women with advanced breast cancer.
Psychooncology, 12, 709-719.
caregiver activity survey (CAS): Development and validation of a new measure for caregivers of persons with Alzheimer’s disease.
International Journal of Geriatric Psychiatry, 12, 978-988.
Dura, J. R., Haywood-Niler, E., & Kiecolt-Glaser, J. K. (1990). Spousal caregivers of persons with alzheimer's and parkinson's disease dementia:
A preliminary comparison. Gerontologist, 30(3), 332-6.
Deitra, L., & Barbara, B. (2000). Helping women and their families cope with the impact of gynecologic cancer. Journal of Obstetric,
Gynecologic, and Neonatal Nursing, 29(6), 653-660.
Esther, S., Catherine, G., Shear, M. K., & Carol, A. (2004). Maternal caregiving strain as a mediator in the relationship between child and mother mental health problems. Social Work Research, 28(4), 211.
Elmstahl, S., Malmberg, B., & Annderstedt, L. (1996). Caregivers burden of patients 3 years after stroke assessed by a novel caregiver burden sacle.
Archives of Physical Medicine and Rehabilitation, 77, 177-82.
Feeney, S. L. (2004). The relationship between pain and negative affect in older adults: Anxiety as a predictor of pain. Journal of Anxiety
Disorders, 18(6), 733-44.
Ferrell, B. R., Dow, K. H., Leigh, S., Ly, J., & Gulasekaram, P. (1995).
Quality of life in long-term cancer survivors. Oncology Nursing Forum,
22(6), 915-22.
Flaskerud, J. H., & Tabora, B. (1998). Health problems of low income
International, 19, 23-36.
Flaskerud, J. H., Carter, P, A., & Lee, P. (2000). Distress Emotions in Female Caregivers of People With AIDS, Age-Related Dementias, and Advanced-Stage Cancers. Perspectives in Psychiatric care, 36(4), 121-130.
Franka, J. M., Jos, A. C., Johannes, F., Niek, S., & Louise, J. (2001). Caring for relatives with dementia Caregiver experiences of relatives of
patients on the waiting list for admission to a psychogeriatric nursing home in The Netherlands. Social Work ResearchScand J Public Health,
29, 113-121.
Frias, C. M., Tuokko, H., & Rosenberg, T. (2005). Caregiver physical and mental health predicts reactions to caregiving. Social Work
ResearchScand J Public HealthAging and Mental Health, 9(4),
331-336.Gallant, M., & Connell, C. (1997). Predictors of decreased self-care among spouse caregivers of older adults with dementing illnesses. Journal of
Aging & Health, 9(3), 373-395.
Galloway, S., Rebeyka, D., Saxe-Braithwaite, M., Bubela, N., & McKibbon, A. (1997). Discharge information needs and symptom distress after abdominal aortic surgery. Canadian Journal of Cardiovascular Nursing,
8(3), 9-15.
Gaugler, J. E., Hanna, N., Linder, J., Given, C., Tolbert, V., & Kataria, R.
(2005). Cancer caregiving and subjective stress : A multi-site, multi-dimensional analysis. Psycho-oncology, 14, 771-785.
Validation of the brief pain inventory in a taiwanese population.
Journal of Pain Symptom Managet,18(5), 316-22.
George, L. K., & Gwyther, L. P. (1996). Caregiver well-being : A multidimensional examination of family caregivers of demented adults. Gerontology, 26(3), 253-259.
Given, B. A., & Given, C. W. (1998). Health promotion for family
caregivers of chronically ill elders. Annual Review of Nursing Research,
16, 197-217.
Given, C. W., Given, B., Stommel, M., Collins, C., King, S., & Franklin, S.
(1992). The caregiver reaction assessment (CRA) for caregivers to persons with chronic physical and mental impairments. Research in
Nursing & Health, 15(4), 271-83.
Given, B., Given, C., & Kozachik, S. (2001). Family Support in Advanced Cancer.CA-A cancer Journal for Clinicians,51(4), 213-231.
Given, B., Wyatt, G., Given, C., Sherwood, P., Gift, A., DeVoss, D., &
Rahbar, M. (2004). Burden and Depression Among Caregivers of Patients With Cancer at the End of Life.Oncology Nursing Forum,
31(6), 1105-1115.
Goldstein, N. E., Concato, J., Fried, T. R., Kasl, S. V., Johnson-Hurzeler, R.,
& Bradley, E. H. (2004). Factors associated with caregiver burden among caregivers of terminally ill patients with cancer. Journal of
Palliative Care, (1), 38-43.
Goodman, C. (1986). Research on the informal carer: A selected literature review. Journal of Advanced Nursing, 11(6), 705-712.
Supportive Oncology, 3(5), 349-359.
Grov, E. K., Fossa, S.D., Tonnessen, A., & Dahl, A. (2006). The caregiver reaction assessment psychometrics and temporal stability in primary caregivers of Norwegian cancer patients in late palliative phase.
Psycho-Oncology, 15, 517-527.
Happe, S., & Berger, K. (2002). The association between caregiver burden and sleep disturbances in partners of patients with Parkinson’s disease.
Age and Ageing, 31, 349-354.
Harrington, V., Lackey, N., & Gates, M. (1996). Needs of caregivers of clinic and hospice cancer patients. Cancer Nursing, 19(2), 118-125.
Heuvel, E. P., Witte, L. P., Schure, L. M., Sanderman, R., & Jong, B. M.
(2001）. Risk factors for burn-out in caregivers of stroke patients and possibilities for intervention. Clinical Rehabilitation., 15, 669-677.
Holly, E., Lincoln, N. B., & Clarke, D. D. (2003). Caregiver strain in spouses of stroke patienys. Clinical Rehabilitation.,17, 312-317.
Holroyd, E., Cheung, Y. K., Cheung, S. W., Luk, S. W., & Wong, W. W.
(1998). A Chinese cultural perspective of nursing care behaviours in an acute setting. Journal of Advanced Nursing, 28(6), 1289-1294.
Hudson, P., & Hayman-White, K. (2003). Measuring the psychosocial characteristics of family caregivers of palliative care patients:
psychometric properties of nine self-report instruments. Journal of pain
IPSP. (1979). Pain terms: A list with definitions and notes on usage.
Recommended by the iasp subcommittee on taxonomy. Pain, 6(3), 249.
Jacobi, C. E., den Berg, B. v., Boshuizen, H. C., Rupp, I., Dinant, H. J., &
van den Bos, G. A. M. (2003). Dimension-specific burden of caregiving among partners of rheumatoid arthritis patients. Rheumatology, 42(10), 1226.
Jensen, S., & Given, B. (1991). Fatigue affecting family caregivers of cancer patients. Cancer Nursing, 14(4), 181-187.
Janssen, S. A., Spinhoven, P., & Arntz, A. (2004). The effects of failing to control pain: An experimental investigation. Pain, 107(3), 227-33.
Job, N., Wilma, J. M. S., Werner, B. F. B., Bernard van, d. B., Marc, A. K.,
& Geertrudis, A. M. (2004). Instruments for assessing the burden of informal caregiving for stroke patients in clinical practice: A
comparison of csi, cra, scq and self-rated burden. Clinical
Rehabilitation, 18(2), 203.
Joshi, G., & Ogunnaike, B. (2005). Consequences of inadequate
postoperative pain relief and chronic persistent postoperative pain.
Anesthesiology Clinics of North America, 23(1), 21-36.
Juarez, G., & Ferrell, B. (1996). Family and caregiver involvement in pain management. Clinics in Geriatric Medicine, 12(3), 531-547.
Kalkman, C. J., Visser, K., Moen, J., Bonsel, G. J., Grobbee, D. E., & Moons, K. G. (2003). Preoperative prediction of severe postoperative pain. Pain,
105(3), 415-23.
Kechlund, G., & Åkerstedt, T. (1997). Objective components of individual
217-220.
Kevin, B., Doris, H., Michel, B., Paul, K., & Christine, H. (2005).
Preferences for place of care and place of death among informal caregivers of the terminally ill. Palliative Medicine, 19(6), 492.
Kramer, B. (1997). Gain in the caregiving experience : Where are we ? What next ?. The Gerontologist, 37, 218-232.
Kuhn, S., Cooke, K., Collins, M., Jones, J. M., & Mucklow, J. C. (1990).
Perceptions of pain relief after surgery.[see comment]. British Medical
Journal, 300(6741), 1687-90.
Kurtz, M. E., Kurtz, J. C., Given, C. W., & Given, B. A. (1993). Loss of physical functioning among patients with cancer : A longitudinal view.
Cancer Pract, 1(4), 275-281.
Kurtz, M. E., Kurtz, J. C., Given, C. W., & Given, B. A. (1994). The Interaction of Age, Symptoms, and Survival Status on Physical and Mental Health of Patients with Cancer and Their Families. Cancer
Supplement, 74(7), 2071-2078.
Kurtz, M., Kurtz, J. C., Given, C. W., & Given, B. A. (1995). Relationship of caregiver reactions and depression to cancer patients’ symptoms,
functional states and depression- A longitudinal view. Social Science
and Medicine, 6, 837-846.
Kurtz, M. E., Kurtz, J. C., Given, C. W., & Given, B. A. (2004). Depression and physical health among family caregivers of geriatric patients with cancer--a longitudinal view. Medical Science Monitor, 10(8),
CR447-56.
Randomized, Controlled Trial of a Patients/ Caregiver Symptom Control Intervention: Effects on Depressive Symptomatology of Caregivers of Cancer Patients. Journal of Pain and Symptom
Managment, 30(2), 112-122.
Leger, D., Guilleminault, C., Dreyfus, J. P., Delahaye, C., & Paillard, M.
(2000). Prevalence of insomnia in a survey of 12,778 adults in france.
Journal of Sleep Research, 9(1), 35-42.
Lewis, F. M. (1999). Family issue in cancer care. In Miaskowski, C. &
Buchse, P. (eds.), Oncology Nursing: Assessment and Clinical Care (pp. 319-331). Missouri: Mosby.
Li, W. W., Lee, T. W., Lam, S. S., Ng, C. S., Sihoe, A. D., Wan, I. Y., et al.
(2002). Quality of life following lung cancer resection: Video-assisted thoracic surgery vs thoracotomy. Chest, 122(2), 584-9.
Lieberman, M. A., & Fisher, L. (2001). The effects of nursing home placement on family caregivers of patients with alzheimer's disease.
Gerontologist, 41(6), 819.
Liu, C., Fan, S., Lo, C., Wong, Y., Ng, I., Lam, C., et al. (2004). Abdominal drainage after hepatic resection is contraindicated in patients with chronic liver diseases. Annals of Surgery, 239(2), 194-201.
Lori, L. B., & Charles, A. G. (2003). Two models of caregiver strain and bereavement adjustment: A comparison of husband and daughter caregivers of breast cancer hospice patients. The Gerontologist, 43(6), 808.
Parental burden, coping, and family functioning in primary caregivers of children with joubert syndrome. Journal of Child Neurology, 14(10), 642.
Marthay, J. (1996). Burden and health outcomes of family caregivers of hospitalized bone marrow transplant patients. Journal of Advanced
Nursing, 24, 915-923.
Mellon, S., Northouse, L., & Weiss. L. (2006). A population-based study of the quality of life of cancer survivors and their family caregivers.
Cancer Nursing, 29(2), 120-131.
McCaffery, M. (1980). Understanding your patient's pain. Nursing, 10(9),
26-31.
McEnany, G. W., Hughes, A. M., & Lee, K. A.(1996). Depression and HIV.
Nursing of North America,37(1), 57-80.
McMillan, S., & Mahon, M. (1994). The impact of hospice services on the quality of life of primary caregivers. Oncology Nurse Forum, 21(7), 1189-1194.
Melzack, R. (1999). From the gate to the neuromatrix. Pain, Suppl 6,
S121-6.
Melzack, R., & Wall, P. D. (1965). Pain mechanisms: A new theory. Science,
150(699), 971-9.
Mellon, S., Northouse, L., & Weiss. L. (2006). A population-based study of
Cancer Nursing, 29(2), 120-131.
Mor, V., Guadagnoli, E., & Wool, M. (1987). An examination of the concrete service needs of advanced cancer patients. Journal of
Psychosocial Oncology, 5, 1-17.
Mystakidou, K., Tsilika, E., Parpa, E., Katsouda, E., Galanos, A., & Vlahos, L. (2004). The Hospital Anxiety and Depression Scale in Greek cancer patients: psychometric analyses and applicability. Support Care in
Cancer, 12, 821-825.
National Alliance for Caregiving & American Association Rertired Person.
(2004). Caregiving in the U.S. Retrieved December 18, 2005, from http://www.caregiving.org/data/04finalreport.pdf.
Ncoli-Israel, S., & Roth, T. (1999). Characteristics of insomnia in the united states: Results of the 1991 national sleep foundation survey. I. Sleep, 22 Suppl 2, S347-53.
Nelson, R., Tse, B., & Edwards, S. (2005). Systematic review of
prophylactic nasogastric decompression after abdominal operations.
British Journal of Surgery, 92(6), 673-680.
Nijboer, C., Triemstra, M., Tempelaar, R., Sanderman, R., & van, d. B.
(1999). Measuring both negative and positive reactions to giving care to cancer patients : Psychometric qualities of the caregiver reaction assessment (CRA). Social Science and Medicine, 48, 1259-1269.
(1999). Determinates of caregiving experiences and mental health of partners of cancer patients. Cancer, 86, 577-588.
Nijboer, C., Triemstra, M., Tempelaar, R., Mulder, M., Sanderman, R., &
van, d. B. (2000). Patterns of caregiver experiences among partners of cancer patients. Gerontologist, 40(6), 738.
Oberst, M. T., Thomas, S. E., & Gass, K. A. (1989). Caregiving demands and appraisal of stress among family caregivers. Cancer Nursing, 12, 209-215.
Oates, J. D., Snowdon, S. L., & Jayson, D. W. (1994). Failure of pain relief after surgery. Attitudes of ward staff and patients to postoperative analgesia. Anaesthesia, 49(9), 755-8.
Osoba, D., Zee, B., Warr, D., Latreille, J., Kaizer, L., & Pater, J. (1997).
Effect of postchemotherapy nausea and vomiting on health-related quality of life. The quality of life and symptom control committees of the national cancer institute of canada clinical trials group. Supportive
Care in Cancer, 5(4), 307-313.
Pai, D., Sharma, A., Kanungo, R., Jagdish, S., & Gupta, A. (1999). Role of abdominal drains in perforated duodenal ulcer patients: A prospective controlled study. Australian & New Zealand Journal of Surgery, 69(3), 210-213.
Pakenham, K. I. (2001). Application of a stress and coping model to
caregiving in multiple sclerosis. Psychology Health and Medicine, 6(1), 13-27.
Pal, P. K., Thennarasu, K., Fleming, J., Schulzer, M., Brown, T., & Calne, S.
patients with parkinson's disease and in their caregivers. Parkinsoism &
Related Disorders, 10, 157-168.
Payne, S., Smith, P., & Dean, S. (1999). Identifying the concerns of informal carers in palliative care. Palliative Medicine, 13, 37-44.
Poulshock, S., & Deimling, G. (1984). Families caring for elders in
residence: Issues in the measurement of burden. Journal of Gerontology,
39(2), 230-239.
Power, I. (2005). Recent advances in postoperative pain therapy. British
Journal of Anaesthesia, 95(1), 43-51.
Proot, I., Abu-Saad, H., Crebolder, H., Goldsteen, M., Luker, K., &
Widdershoven, G. (2003). Vulnerability of family in terminal palliative care at home ; balancing between burden and capacity. Scandinavian
Journal of Caring Sciences, 17, 113-121.
Pud, D., Eisenberg, E., Spitzer, A., Adler, R., Fried, G., & Yarnitsky, D.
(1998). The nmda receptor antagonist amantadine reduces surgical neuropathic pain in cancer patients: A double blind, randomized, placebo controlled trial. Pain, 75(2-3), 349-54.
Robinson, B. C. (1983) Validation of a caregiver strain index. Journal of Gerontology, 38(3), 344-348.
Robinson, B. C. (1983) Validation of a caregiver strain index. Journal of Gerontology, 38(3), 344-348.