癌末接受「安寧緩和共同照護」病人之症狀與照顧措施的探討

Exploration of Distress Symptoms and Medical Interventions in Patients With Terminal Cancer in Hospice Shared Care

背景：「安寧共同照顧（安寧共照）」是癌末廣泛應用的照顧方式，需隨著末期病人疾病進展提供適當的措施，積極改善症狀的照顧，直到病人生命終止。目的：了解癌末病人接受「安寧共照」期間之症狀，並比較共照前、後症狀嚴重度之變化與醫療團隊提供之照顧內容。方法：縱貫性類實驗性研究，方便取樣50位接受安寧共照且預估生命存活期不大於6個月之癌末病人。結果：癌末病人症狀各分類之發生比率與其嚴重度排序前三項，生理症狀為「疼痛」、「虛弱」與「呼吸困難」；嚴重度為「疼痛」、「虛弱」與「睡眠困擾」；心理症狀為「憂鬱」、「擔心病情」與「怕拖累他人」，嚴重度為「憂鬱」、「焦慮」與「擔心病情」；社會靈性症狀發生比率與嚴重度皆為「心願未了」、「經濟困難」與「痛苦無意義」。研究期間病人症狀的嚴重度有逐漸緩和的趨勢，而心理症狀嚴重度達顯著的改善。安寧共照之原醫療團隊提供的照顧措施排序之前三項，非藥物類為「管路照顧」、「檢驗」與「傷口照顧」；藥物類為「症狀控制用藥」、「抗生素注射」與「大量輸液用藥注射」；問題協調與會談類排序前三項為「病情預後的認知澄清」、「不施行維生醫療討論與簽署」與「情緒壓力的會談」。安寧專科團隊為問題協調與會談類之「情緒壓力的會談」、「團隊溝通」與「病情預後的認知澄清」；非藥物類為「按摩」、「會診」與「護理指導」。結論/實務應用癌末病人症狀的調查，提供臨床人員盡快掌握評估方向，醫療跨專業領域之人力投入安寧療護多樣化的照顧事務，使症狀控制有正面的成效，此可作為推動安寧共照的參考。

Background: Hospice shared care is a model of care widely used in patients with terminal cancer. Appropriate interventions to improve related symptoms should be provided during disease progression through the end of life. Purpose: The purpose of this study was to explore the related symptoms and to compare symptom severity before and after the implementation of hospice shared care and medical care interventions. Methods: Fifty patients with terminal cancer were enrolled in this longitudinal, quasi-experimental research. Inclusion criteria included having an expected life span of < 6 months and agreeing to enter hospice shared care. Result: The three most-frequently noted physical symptoms were, in rank order: “pain”, “weakness”, and “dyspnea”. In terms of severity, “pain” was the most severe, followed by “weakness” and “disturbance of sleep”. The three most-frequently noted psychological symptoms were, in rank order: “depression”, “worry about the disease”, and “afraid of dragging others down”. In terms of severity, “depression” was the most severe, followed by “anxiety” and “worry about the disease”. The frequency and severity of the top-3 social and spiritual distress symptoms were, in rank order: “unfinished wish”, “economic difficulties”, and “painlessness”. During the study period, the severity of physical symptoms improved gradually, while the severity of psychological symptoms improved significantly. The top- 3 items in the original medical team’s hospice-care interventions were, in rank order: “tube care”, “laboratory test”, and “wound care” in the non-pharmacological category; “symptom control medication”, “antibiotic injection”, and “intravenous fluid infusion” in the pharmacological category; and “cognitive clarification of the prognosis condition”, “do not conduct resuscitation discussions and signing”, and “emotional stress consoling” in the problem-coordination and interview categories. The interventions implemented by the hospice specialist team included “emotional stress interview”, “team communication”, and “cognitive clarification of prognosis condition” in the problem coordination and interview categories, and “massage”, “consultation”, and “nursing advice” in the non-pharmacological category. Conclusions / Implications for Practice: The symptoms identified in this study provide clinical staff with a reference for the rapid assessment of patients with terminal-stage cancer. Manpower from various professional fields are committed to providing diversified services in the care teams, which positively affect the control of related symptoms. The experience presented in this article may be used as a reference to promote the hospice shared care model.