影響病人違背醫囑自動出院之因素探討─以某區域
醫院為例
本研究旨在探討影響違背醫囑自動出院病人在個人及醫療因素上的特色，病人與臨床醫
師對於醫療服務的期待與感受之間的差異。以北部某區域醫院 350 位違背醫囑自動出院
病人個案病歷分析，及隨機挑選同時期 350 位經醫師許可出院病人為研究對象，利用回
溯性資料進行分析，採用 Logistic Regression 預測各變數發生之機率，另模擬 PZB 模式
設計結構式問卷測量違背醫囑自動出院病人及臨床醫師對於醫療服務期待與感受之落差
缺口。研究結果發現違背醫囑自動出院病人與醫師許可出院病人在人口學特質及醫療因素上均
有顯著差異，以羅吉斯迴歸分析，預測其發生違背醫囑出院之機率：內科病人為外科病
人的 2.99 倍、從急診簽住院為門診簽住院的 2.32 倍、無住院經驗者為有住院經驗者的
1.82 倍、男性為女性的 1.57 倍，另居住在當地及住院期間有人陪伴者發生違背醫囑出
院之機率明顯較低（ p<0.001 ）。在醫療結果方面，預測出院後 14 天再住院率違背醫
囑自動出院為醫師許可下出院的 2.06 倍。有關違背醫囑出院病人及醫師對於醫療服務
的期待與感受，利用問卷資料統計後發現，在 PZB 模式之服務五大構面無論是有形性
、可靠性、反應性、關懷性、保證性皆達顯著差異，其中以關懷性的落差最大。
依據研究結果建議臨床醫療人員當病人住院進行評估時，若有易違背醫囑出院之特質，
則應儘早與病人討論並擬定醫療計畫，以降低違背醫囑出院機率，縱使其出院後亦能有
完善的醫療照護體系接手。此外，考量病人出院是在尚未完成治療之階段，基於尊重病
人自主權及避免後續爭議，完整的文件記錄是必要的。舉辦醫療人文教育對臨床服務工
作者而言有助於醫病關係及醫療品質之提升，可以促進醫療服務之可近性。
The Study of Against Medical Advice Discharge Fa
ctors-A Reginal Hospital Experience
Objectives: This study investigates the against medical advice (AMA) discharges concludes that the majori ty of the AMA patients leave hospitals for personal and medical reasons. There are medical perception and experience gaps between patients and physicians.
Methods: A retrospective chart review and a matching survey based on PZB model was performed. A total of 350 AMA patients discharged from a regional teaching hospital were compared retrospectively with ano ther 350 general physician-approved discharged patients during the same period. The questionnaire compar es the medical perception and experience from patients discharged AMA and their attending physicians.
Results: Patients who leave hospital against medical advice differ from the general patient population. Logi stic regression was performed to predict discharge status from the admission factors. They include a higher proportion of male gender (odds ratio [OR] 1.57; 95% confidence interval [CI] 1.12~2.19),non-hospitalizat ion experiences (OR 1.82; 95% CI 1.33~2.47), admission through the emergency department (OR 2.32; 95
% CI 1.63~3.32), general medical patients(OR 2.99; 95% CI 2.11~4.23), living in other city (p<0.001) and lack of accompanying at the time of admission (p<0.001). Predicators of readmission with 14days(OR 2.06
; 95% CI 0.9651~4.38). Regarding medical perception and experience appear to be significant on reliabilit y, assurance, responsiveness, and empathy aspects. The largest gaps in five constructed differentials is emp athy.
Conclusions: The study establishes a profile of AMA patients leave hospital. Early identification of targete
d patients may facilitate this process. Such as, early discharges planning for appropriate outpatient treatme
nt are recommended, thereby decreasing readmission and improving health outcomes. One challenge that p
atients who leave hospital AMA authority may not best interest and the doctrine of informed consent, so co
mprehensive documentation should be planned and reinforced. It has been suggested in postgraduate medic
al education. Healthcare quality professionals should also receive formal training on patient relations as par
t of the management program, programs to improve continuity of care and to provide easier access to the h
ealth care system.
