成人加護病房安寧緩和醫療使用──現況調查及其差異比較

Utilization of Hospice Resources in Adult Intensive Care Units: A Comparison Between Users and Non-Users

背景加護病房運用安寧緩和醫療資源的使用狀況，因受到病人診斷複雜、病況緊急多變等因素影響，一直面臨諸多挑戰。即便研究及國際共識均鼓勵早期運用安寧緩和醫療資源，然而安寧緩和醫療在加護病房之利用率仍偏低，導致末期病人接受無效醫療之機率增加及較差的死亡品質。為改善上述臨床現況，首要須對加護單位安寧緩和醫療資源使用之現況有全面性的了解。
目的調查成人加護病房病人之安寧緩和醫療資源使用現況，並比較使用者與未使用者之差異。
方法本研究為回溯式相關性研究（retrospective correlation study），自北台灣一醫學中心之成人加護病房資料庫選取2022年6月1日到7月31日之個案，運用描述性統計、獨立樣本t檢定及卡方檢定進行分析。
結果本研究共分析1,181人，含458位女性（38.8%）及723位男性（61.2%）。共發現217人（18.4%）有使用安寧緩和醫療資源。其中「急需安寧緩和醫療資源者」，亦即加護病房入院30天內死亡者，共有124人（10.6%）；此族群仍有20.2%（n = 25）未曾使用安寧緩和醫療資源。比較使用與未使用安寧緩和醫療資源者，其在年齡、疾病別、虛弱程度、心搏停止、感染、意識狀態、插管、氣切造口、強心升壓藥物、腎臟替代療法、葉克膜置放、譫妄、Sequential Organ Failure Assessment及Acute Physiology and Chronic Health Evaluation III分數上有顯著差異。
結論／實務應用約兩成具急迫需要者無法即時使用安寧緩和醫療資源，顯示目前之醫療決策依據，仍有可討論之空間。結果呈現有使用與無使用安寧緩和資源之組間有多面向之差異，顯示醫療團隊廣泛考量各面向因子以判斷安寧緩和醫療需求，但如何選定更精準且具經濟效益之決策輔佐指標，以協助安寧緩和醫療資源啟動與分配之判斷，為未來研究與臨床實踐之要務。

Background: The application of palliative care is limited and challenging in intensive care units (ICUs) because of complex factors such as time constraints and unpredictable disease progression. Although research results and international consensus stress the early use of palliative care, utilization remains low, resulting in increased risks of ineffective medical care and poor quality of death. Improving this situation requires a comprehensive understanding of the palliative condition in ICUs. Purpose: This study was designed to investigate the utilization of hospice resources in adult ICUs and to compare this utilization between users and non-users. Methods: This retrospective correlation study recruited cases from the adult ICU database of a medical center in northern Taiwan between June and July 2022. Descriptive statistics, independent t-test and chi-square were used to analyze the data. Results: A total of 1,181 records were analyzed, including 458 (38.8%) females and 723 (61.2%) males. Two hundred and seventeen cases (18.4%) used hospice resources. Although 124 (10.4%) of the 1181 cases were identified as“in urgent need of hospice resources”(i.e., died within 30 days of ICU admission), 25 (20.2%) did not use these resources. Significant differences between the urgent-need cases who did and did not use hospice resources were found in terms of age, disease type, degree of frailty, cardiac arrest, infection, state of consciousness, intubation and tracheostomy status, inotropic and vasopressor medication, renal replacement, ECMO placement, delirium, and Acute Physiology and Chronic Health Evaluation III and Sequential Organ Failure Assessment Scores. Conclusions/ Implications for Practice: The roughly 20% of ICU patients in urgent needs of palliative care who did not utilize palliative care resources highlight the needs for continued discussion to better assist patients on palliative care decision-making. The findings show multifaceted differences between those who did and did not access palliative care. Future studies should design and test strategies to facilitate the identification of palliative care needs and ensure the effective allocation of palliative care resources in ICUs.