加護病房肝硬化病人DNR醫療決策及預測因子之探討

An Exploration of Predictive Factors and DNR Medical Decision of Patients with Liver Cirrhosis in ICU

研究目的：探討加護病房肝硬化病人不施行心肺復甦術（DNR）醫療決策之經驗材料與方法：採電子病歷回溯性調查設計，以加護病房2013年8月1日至2015年7月31日（共2年）肝硬化個案共236位進行分析，並以自擬結構性調查表進行資料收集及統計。結果：DNR宣導的比率為41.9%（n=99），入院到宣導DNR平均時間為7.10（SD=828）天，其中婚姻狀況及腎絲球過濾率（GFR），是影響DNR宣導之預測因素，勝算比（OR）分別為2.056（95% C1=10124175）、0.979（95%CI=0.962-0.996）。而DNR簽署的比率為36.9%（n = 87），入院到簽署DNR之平均時間為9.64（SD=11.04）天，其中年齡、總膽紅素、腎絲球過濾率（GFR）是影響DNR簽署之預測因素，勝算比（OR）分別為1.032（95%CI=1.001-1.063），1.076（95%CI=1.007-1.149），0.970（95%CI = 0.950-0.990）。結論：腎臟衰竭是影響肝硬化病人DNR宣導，簽署之預測因子，當肝硬化病人發生腎功能不全時，病情惡化快速，醫療人員若能提早掌握宣導DNR的時機並及時提供緩和醫療之治療方針，方可避免無效之延命醫療。

Objectives: To explore the experience of the DNR medical decision of patients with Liver Cirrhosis in ICU. Method: The investigation was carried out using the medical e-records of 236 cases of Liver Cirrhosis from August 1^(st) 2013 to July 31^(st) 2015. The analysis was made through data and information collected from a self-structural survey. Result: In the analysis of the average ratio of DNR advocacy, the percentage of advocacy was 41.9% (n = 99), with an average of 7.1 days (SD=8.28) from hospitalization to DNR advocacy. The predictive factors affecting DNR advocacy were the patient's state of marriage, and GFR (Glomerular filtration rate), with odds ratios of 2.056 (95% CI=1.012-4.175) and 0.979 (95% CI=0.962-0.996) respectively. In another analysis of the ratio of declaring DNR, the percentage of declaration was 36.9% (n=87), with an average of 9.64 days (SD=11.04) from hospitalization to declaring DNR. The predictive factors affecting the declaration of DNR were age, total bilirubin and GFR, with odds ratios 1.032 (95% CI=1.001-1.063), 1.076 (95% CI= 1.007-1.149) and 0.970 (95% CI=0.950-0.90) respectively. Conclusion: Renal failure is the most prominent predictive factor that affects the advocacy and declaration of DNR of patients with Liver Cirrhosis. If the dysfunction of the kidneys occurs on a patient with Liver Cirrhosis, the medical situation of the patient will worsen significantly within a small timeframe. Thus, if the medical crew is able to control the timing of DNR advocacy and provide proper medical treatment of mitigation, ineffective and unhelpful treatment can be avoided.