影響醫療人員不施行急救決策的因素探討
背景:隨著醫療科技發展,人們對醫療結果的期待也隨之升高,往往在面對醫療行為時,抱持著盡力救治總會有希
望的態度,或是至少做到延長生命的期許,尤其近期一些醫療案件的新聞報導,導引人們越來越認為即使心肺停止
之後,仍有回復的希望。但醫療行為與技術是否已經被人們過度期望與使用,同時在心肺停止後所使用的非常醫療
,所衍生而來的法律、倫理與醫療資源等問題,將會是未來更須重視與討論之議題。其實心肺復甦術所帶來的後遺
症及後續照顧的問題,徒然造成醫療體系及資源的龐大負擔。因此不予施行心肺復甦術 (Do Not Resuscitation; DNR)
或許應該是醫療行為的選項之一。但在不同醫療院所、不同科別醫師以及不同病情變化下,對於不予施行心肺復甦
術有著相當程度差異的見解。
目的:本研究的主要目的在探討醫療人員對不施行急救之認知與態度,以及探討本國醫療人員不施行急救決策之影
響因素。方法:本研究以自行研發之問卷為研究工具,調查醫院包括醫學中心與區域教學醫院各一家,人員涵蓋此兩家醫院
中所有急診、加護病房之醫師與護理人員,以及內外科醫師。問卷包含三大部份,首先,收集過去文獻上曾提出之
影響醫療人員進行不施行急救之相關決策因素,設計出模擬之案例情境,同時進行我國專家的訪談,列出本國醫療
人員可能會考慮之相關因素,結合階段性情境納入決策因素,之後納入認知與態度問題,讓受測者除針對情境提出
他將進行之決策之行為強度外,並測量其對此議題之認知與態度上與行為是否有不同之處。進一步統計分析醫療人
員間對 DNR 認知與態度之差異性,以及影響決策之相關因素。
結果:以 97 年 3 月份現職人數共發出 1086 份,回收 762 份,回收率 70.2% ,調查對象中醫學中心發放問卷為 839
人次,總共回收 624 份,回收率 74.4% 。區域教學醫院發放問卷為 247 人次,總共回收 138 份,回收率 55.9% 。經
刪除資料不完整之問卷後,有效問卷為 673 份。研究發現隨著病人不同病情之變化下,醫療人員對於是否提出 DNR
的決策因素也隨之改變,但法律問題考量則是持續被注重的,而最重要的因素為家屬意願,其他包括有病人清醒時
意願、病人年齡等因素。而單看醫師部分其考量因素較全體人員不同之處為為考量病人有失智情形。家屬是否簽署
DNR 同意書對所有醫療人員所提供之醫療處置皆會有所影響( p<0.01 ),但對醫師而言並不會影響其是否會對病
人提供靜脈輸液之治療。而 DNR 之認知部分,相關知識測驗全體醫療人員平均得分 64.48 ,醫師平均得分 65 分,
且一致對於「醫師是否可依據病情不論病人與家屬之意願來判斷是否進行 DNR 」、「 DNR 一簽署後時效性問題」
此兩觀點感到混淆不清。
結論:從本研究結果呈現影響醫療人員不施行急救之決策影響因素,最重要的為家屬意願或共識以及法律因素,而
有無同意書對醫療行為有顯著影響,而對 DNR 認知部分已有相當水準,但測驗題整體得分不高,且一致針對某些
議題仍有爭議,因此研究結果可當成未來進行教育或討論之議題參考。
Factors Influencing the Decision-making of Health
Care Professionals Regarding Do-Not-Resuscitate
Background: With development of medical technology, people’s expectation from medical out come is increased. They usually hold a last hope to help prolong lives. But there arise hot issu es about over-expectation of medical outcomes or techniques and the sequential problems with respect to laws, ethics and medical resourses after fruitless cardiopulmonary resuscitation. In t hese circumstances, “DO-NOT-RESUSCITATE” (DNR) order may well be an option.
Purpose: The objective of this study is to investigate the knowledge and attitude of medical pe rsonnel regarding DNR. Also factors affecting the decision-making of medical personnel abou t DNR in our country are studied.
Methods: Self-made questionnaire was used to investigate medical personnel in two hospitals (one medical center and the other regional hospital). Participants were physicians and nurses a t emergency room and intensive care unit and internists and surgeons. The questionnaire was d ivided into three parts and designed to simulate case scenarios. Participants were allowed to ch oose the response behavior and intensity as well as the affecting factors.
Results: One thousand and eighty six copies of questionnaire were issued. The response rate w as 70.2%. With change of patient condition, medical personnel’s decision-makings were also a ltered. The most important factors were family’s will and laws. Other factors included patients
’ conscious will and patient age. The mean score about DNR knowledge was 64.48. Participan ts had uniformly confusions about the expiry after DNR orders were signed.
Conclusions: The most important factor affecting medical personnel’s DNR was law sues and
family’s will. The study results could be for reference topics about medical education in the fu
ture.