家庭為中心預立醫療照護諮商對失智者及家庭照顧者末期照護決策衝突之影響

The Impact of Family-Centered Advance Care Planning for Persons With Dementia and Family Caregivers on Decision-Making Conflicts in End-of-Life Care

背景：失智早期階段參與預立醫療照護諮商對於生命末期照護品質與照護決策至關重要。失智者與其家庭照顧者缺少預立醫療照護諮商及末期照護討論，常會導致失智末期照護決策衝突。目的：探討以「家庭」為中心的預立醫療照護諮商訊息介入對輕度失智者與其家庭照顧者的生命末期照護決策衝突的影響。方法：本研究採前實驗–單組配對前後測設計，在北台灣區域教學醫院的門診進行收案。參與者是經醫師診斷之輕度認知障礙或輕度失智者，及其家庭照顧者配對組成，共43對。介入措施由受過訓練的資深護理師使用預立醫療照護諮商手冊以家庭為中心的策略進行，以決策衝突量表作為主要資料收集，以成對t檢定等統計方式比較介入前及介入後四週的差異。結果：預立醫療照護諮商訊息介入顯著降低輕度失智者的生命末期照顧決策衝突（p＜.001），各面向決策衝突均有顯著下降，其中下降幅度依序為價值澄清面、不確定面，以及有效決策面。而家庭照顧者在介入後對於長者的生命末期照護決策衝突總分亦顯著減少（p＜.001），唯在支持面未達顯著差異。結論：以家庭為中心的照護策略提供失智症的生命末期照護相關知識，促進失智者、家庭照顧者和照護提供者進行動態及持續性的溝通，有助於減少生命末期照護決策衝突。

Background: Participating in advance care planning (ACP) discussions during the early stages of dementia is crucial to ensuring the quality of end-of-life (EoL) care. Inadequate discussions regarding ACP and EoL care between persons with dementia and family caregivers often lead to decisional conflicts when persons with dementia are in the later stages of their disease. Purpose: To explore the impact of a family-centered ACP information intervention on the EoL care decision–making conflicts between persons with dementia and their family caregivers. Methods: A one-group, pretest–posttest, pre-experimental design was applied. Data were collected at outpatient clinics in regional teaching hospitals in northern Taiwan. Participants included 43 dyads of persons diagnosed with mild cognitive impairment or mild dementia and their family caregivers. The intervention was implemented by an ACPtrained senior registered nurse and was guided using ACP manuals and family-centered strategies. The decisional conflict scale was the main measure used. Paired t tests were used to compare differences between pre-intervention data and 4-weeks’ post-intervention data. Results: The ACP information intervention significantly reduced the decisional conflict score for end-of-life decision making in the participants with mild dementia (p < .001). In addition, significant declines were observed in all aspects of decision-making conflicts, including value clarification, uncertainty, and effective decision-making. The mean total conflict score of the family caregivers was also significantly reduced (p < .001), but no significant difference was found in the aspect of support. Conclusions: Family-centered care strategies provide knowledge about end-of-life care for persons with dementia. These strategies also facilitate regular and continuous communication between family caregivers, persons with dementia, and medical professionals, reducing decisional conflicts in EoL care.