加護病房裡生命末期的醫療決策：以簽署不施行心肺復甦術意願（同意）書的決策分析為例   全文下載

End of Life Medical Decision-Making in Intensive Care Unit: An Analysis for Do-Not-Resuscitate (DNR) Designation

本研究論文主旨一方面在分析病人和其家屬，以及照顧他們的加護病房醫師和護理人員的簽署不施行心肺復甦術（Do-Not-Resuscitate, DNR）意願（同意）書決策制定過程，另一方面在討論影響他們在生命末期制定DNR簽署決策的影響因素。研究者採「質性研究法」，藉由半結構式問卷，訪問四種不同身分的研究參與者，訪談文本以「持續比較分析法」進行資料蒐集與分析。
研究發現，加護病房裡生命末期的醫療決策包括三層決策關係的變化：病人與家屬的決策權位移、家屬和醫護人員間決策權的角力及醫護人員間決策權的衝突。同時，醫護人員、家屬與病人在做決策時都受到「認知、情感、治療風險及態度與經驗」四個面向因素所影響。然而，醫護人員易於採取生物醫學模型做出醫療決策；而家屬則傾向於考量家庭整體福利。
值得注意的是，加護病房醫療人員彼此之間各自根據其專業及社會文化面向考量所導致的認知差異，確實會影響簽署DNR的執行過程，且這個內部差異性顯示出加護病房裡的醫師與護理人員並非總是擁有醫療決策共識，也不會彼此貢獻充分資訊。

This article aims to analyze decision making process of Do-Not-Resuscitate (DNR) designation between end of life patients, their family members, and their physicians and nurses in ICU. Related factors determining their decision making of DNR designation are also examined. Based on semi-structured questionnaire transcribed interviews with these four main research participators during the decision-making process, the qualitative data are collected and analyzed according to constant comparative method (CCM).
The research findings indicate three changes of DNR decision-making process at the end of life stage in ICU: 1. decision-making power shifting between patients and their family members, 2. decision-making power wrestling between family members and medical care personnel, 3. decision-making power conflicts among medical care personnel. It is also observed that three changes of medical decision-making process are mainly influenced by four dimensions: cognitional, emotional, risks of medical treatment, and attitude / experience. However, it is also found that nursing personnel and physicians are apt to make medical decision based on biomedicine knowledge, whereas family members prefer to make decision in consideration of the whole family welfare.
It is worth noting that the cognitive differences under medical personnel in ICU based mainly on their different professional training and socio-cultural backgrounds, which can substantively influence the implementation process of DNR designation. It is also found this internal cognitive difference even shows that physicians and nursing personnel in ICU don’t build consensus effectively on medical decision, and neither share the whole decision-related information at reciprocal and cooperation-based relation.