洗腎室護理人員推行預立醫囑觀點之前驅性研究

A Pilot Study on the Perspectives of Hemodialysis Room Nurses on Promoting Advance Directives

背景：過去研究指出末期腎病患者的瀕死經驗並不理想及簽署預立醫囑的比例偏低，且病患並不知有選擇終止透析的權利，他們亦相信醫師不會支持這個選擇。由此可知，醫護人員在與病患溝通生命末期治療決策時仍存有許多困境與阻礙。而護理人員是病患所信任、依賴的專業人員，不僅應作病患的代言人，更有責任與其討論並協助完成預立醫囑。
目的：探討洗腎室護理人員推行預立醫囑之觀點及其相關因素。
方法：本研究為描述相關性研究設計。選取55位南台灣某區域醫院洗腎室護理人員。研究工具採自擬結構式問卷，包含基本屬性及護理人員推行預立醫囑之觀點調查問卷。所得資料以描述性及推論性統計含獨立樣本t檢定、單因子變異數分析及皮爾森積差相關。
結果：研究結果發現超過八成護理人員同意「與病人討論預立醫囑，可了解其對醫療處置的期望、改善臨終品質及降低許多臨終衝突與家庭糾紛」，而有78.2%護理人員認為「沒有足夠的訓練可以與病人談論死亡或瀕死的議題」，65.5%護理人員擔心「與病人談論預立醫囑會讓他煩惱或不舒服」且其「工作使命是維持病人生命，而非死亡」。此外，也有43.6%的護理人員認為與病人討論預立醫囑並非我的工作職責。年齡及曾與他人討論過自身臨終時想採取的醫療為影響護理人員推行預立醫囑觀點之相關因素。
結論：預先與病人討論生命終點的照護決策能提升病人終末的生活品質，但臨床護理人員仍受限於缺乏訓練或自身負向觀點而阻礙推行，因此，教導護理人員如何與病人開啟生命末期照護的對話及重視病人末期照護需求為首要努力的方向。

Background: Previous studies have shown that patients with end-stage renal disease experience a lower than optimal quality of dying and achieve a lower rate of advance directives (ADs) completion. Patients are frequently unaware of their option to withdraw from dialysis and also believe their physicians would oppose such a decision. Where there are inherent difficulties for medical staff in discussing end-of-life (EOL) issues with patients, patients on dialysis often develop a trusting, almost familial relationship with their nurses, who play a vital role in assisting patient and family to make EOL care decisions.
Purpose: The purpose of this study was to explore the perspectives on advance directive discussion strategies of nurses working in hemodialysis rooms.
Methods: This was a descriptive-correlational research study that targeted 55 nurses working in a hemodialysis room at a regional hospital in southern Taiwan. Structured questionnaires were developed for this study that collected basic demographic information and assessed participant perspectives on discussing ADs. Data were analysed using descriptive statistics and deductive statistics, including independent t test, one-way ANOVA and Pearson correlation.
Results: Over 80% participants agreed that discussing ADs with patients could accurately identify patient preferences, improve EOL quality, and decrease family conflicts. However, 78.2% expressed that they did not have sufficient training to talk with patients about death and dying. Also, two-thirds (65.5%) worried about upsetting their patients, as they perceived their professional role as sustaining life (rather than helping prepare for death). Significant differences in discussing ADs with patients were found in respect to age and personal experience as well as with regard to whether the participant had discussed EOL care decisions with others.
Conclusion: Discussing ADs with patients may improve EOL quality. Lack of training and negative perspectives represent major barriers. Therefore, teaching nurses how to engage in EOL care dialogue with patients and paying attention to patient EOL needs represent crucial tasks ahead.