加護病房重症臨終病人維生醫療分析

Analysis of Terminally Ill Patients with Life-Sustaining Treatment in the Medical Intensive Care Unit

探討內科加護病房臨終病人接受維生醫療之現況。採電子病歷回溯性調查設計，以2013年8月1日至2015年07月31日入住內科加護病房之臨終病人380人為研究對象。加護病房臨終前有簽署DNR之307位病人中，其簽署DNR前後所接受之維生醫療處置總數有顯著差異（110.1±203.2 vs. 2.45±5.2 p＜0.001）尤以抽血檢查、抽痰、周邊及中心靜脈導管、CPR、洗腎、手術、內視鏡等次數及點滴輸液治療、氣管內插管、呼吸器、鼻胃管、導尿管等使用天數顯著下降，而NIV使用天數顯著上升。簽署DNR後至死亡前仍持續之維生醫療依序為抽血檢查、周邊及中心靜脈導管、鼻胃管、導尿管、呼吸器及氣管內插管等。加護病房末期病人簽署DNR雖然可以顯著下降侵入性醫療處置，但臨終前仍無法完全停止維生醫療。因此建議傷重不可救治之末期病人除儘早介入DNR討論外，仍應實施有效之醫病共享決策，在尊重病人偏好及價值觀之下討論停止無效維生醫療，方能避免病人受苦。 The purpose of this study was to analyze the condition of terminally ill patients who used life-sustaining treatment in the Medical Intensive Care Unit. Electronic medical records were used to design a retrospective study, and 380 terminally ill patients staying in the Medical Intensive Care Unit from August 1, 2013 to July 31, 2015 were used as the target of this study. Among 307 patients who had signed DNR before death, different results in using life-sustaining treatment before and after signing DNR could be obviously shown (110.1±203.2 vs. 2.45±5.2 p<0.001); for example, the times of taking a blood test, sputum suction, having a peripherally inserted central catheter, CPR, dialysis, surgery, and endoscopy particularly decreased. The days of using drip infusions, endotracheal intubation, medical ventilator, nasogastric tube, and urinary catheter also decreased. However, the days of using NIV increased. From the moment of signing DNR to death, the steps of using life-sustaining treatment from blood test, peripherally inserted central catheter, nasogastric tube, urinary catheter, medical ventilator, to endotracheal intubation could not be avoided. Though signing DNR by terminally ill patients in the Medical Intensive Care Unit can obviously decrease the times of using life-sustaining treatment, the use of life-sustaining treatment cannot be completely avoided. Therefore, it is suggested that terminally ill patients who are impossible to survive and recover from illness should be noticed to discuss their willingness of signing DNR as soon as possible. In addition, the effective Shared Decision Making should also be implemented so as to respect patients' preference and value on DNR, helping them refuse futile life-sustaining treatment and prevent them from suffering.