| 摘要: | 我國已邁入高齡化社會，人口結構快速老化，老人入住護理之家需求增加，未來老人在護理之家死亡人數也將日益增加，護理之家住民生命末期照護需求也迫切需要。國內少有護理之家生命末期的相關研究，本研究的目的在了解護理之家住民生命末期症狀，末期醫療及其相關因素。
本研究採回顧性調查，以方便取樣選取兩家護理之家65歲以上死亡病歷共121位研究對象，一家醫院附設型護理之家一家獨立型態護理之家皆位於台灣北部。資料收集，包含人口學特性，日常生活功能和認知狀態，生命末期症狀及徵象，預立醫療計劃和及末期醫療。並以多元迴歸分析來解釋變項和急性醫療就醫之間的關係。資料分析採用PASW/20 PC版軟體統計分析。
研究結果顯示，死亡住民平均年齡為83.99±7.27; 76.8%為男性，78.5%日常生活活動功能完全依賴，83.5%嚴重認知障礙。生命末期常見的症狀包括呼吸困難（86.8%），吞嚥困難（86.8%），消化不良（45.5%），噁心/嘔吐（40.5%），食慾不振（31.4%）， BMI <18.5 kg/m2（28.1%），躁動（22.3%），體重減輕（11.6%）。生命末期六個月有86.8%發生住院、44.6％急診就醫未住院。臨終前，32.2%簽署（Do-Not-Resuscitate，DNR），體外心臟按摩21.5%，氣管插管22.3%，急救藥物注射38.8%，輸血18.2%。年齡、認知功能、食慾不振、躁動、體重減輕及症狀總數與急診就醫未住院有關，經多元迴歸分析後，認知功能及體重減輕是急診就醫未住院的顯著預測因子（F=5.216, p=.000<.05）。入住機構時間、日常生活活動功能與呼吸困難與住院就醫有關，但經多元迴歸分析後，三個變項皆不具顯著預測力。共有十四個變項與末期醫療總類有相關，經多元迴歸分析後，宗教信仰、MMSE分數、疼痛、呼吸困難、躁動及簽署DNR，具有顯著預測力（F=6.879, p=.000<.05）。護理之家住民臨終前接受的末期醫療偏高，生命末期照護的品質在長照機構仍需要努力提升，建議全面性加強醫療人員教育訓練，提升護理之家生命末期照護的品質。
Taiwan has gotten into aging society. The group of older population is grown very fast. Older persons increased demands for nursing home care. The number of older persons died in the nursing home also increased. End-of-life care needs in nursing home residents increasing. There was few research of end-of-life care in nursing home residents. The purposes of this study were to understand signs, symptoms, medical care of end-of-life among nursing home residents and their related factors.
This study used a retrospective chart review. One hundred twenty-one residents who aged 65 and over were from 2 nursing homes, which one teaching hospital and one independent nursing home were located in northern Taiwan. Data were collected regarding demographic variables, functional and cognitive status, signs and symptoms of end-of-life, advance care planning and medical care. Multiple regression analyses were conducted to examine the relationship between residents’ variables and medical care. The data were analyzed by PASW/PC 20 for windows.
The study results showed that the mean age of residents was 83.99 ± 7.27 years; 76.8% of subjects were male, and 78.5 % of subjects were totally dependent, 83.5% of subjects were severe cognitively impaired. Common symptoms and signs of end-of-life among NH residents included shortness of breath (86.8%), swallow difficulty (86.8%), indigestion (45.5%), nausea/vomiting (40.5%), decrease appetite (31.4%), BMI<18.5 Kg/m2 (28.1%), irritability (22.3%), and weight loss (11.6%). 86.8% of subjects had hospital admissions and 44.6% of subjects had emergency room visits occurred within 6 months of end-of-life. Before death, 32.2% of subjects received DNR orders, 21.5% of subjects had cardiac massage, 22.3% of subjects had endotracheal intubation, 38.8% of subjects had emergency medication injection, and 18.2% of subjects had blood transfusion. The age, MMSE score, loss of appetite, irritability, weight loss, and the total number of symptoms had correlation with the frequency of emergency room visits. Multiple regression analysis showed the MMSE score, and weight loss（F=5.216, p=.000<.05）were significant predictors of frequency emergency room visits. Length of stay, ADL score, and shortness of breath had correlation with the frequency of hospital admissions.There were no strong predictors which were identified to predict frequency of hospitalization. Fourteen variables had correlation with the received end-of-life medical care. Multiple regression analysis showed the MMSE score, religion, shortness of breath, irritability, pain, and signed DNR orders were significant predictors of numbers of end-of-life medical treatments. (F=6.879, p=.000<.05)
Our study indicates that higher rate of medical care among NH residents, and most do not receive optimal palliative care. Management and educational strategies are needed to improve end-of-life care in nursing home residents. |
