某醫學中心癌症病童生命末期照護現況探討-2010至2012年病歷回顧

Abstract

研究背景與目的： 癌症為國內外十八歲以下兒童主要死亡原因之一，過去研究顯示癌症病童於死亡前經歷了較多以治癒為目的過度醫療，而安寧緩和療護的使用率則較低。本研究旨在了解1.癌症病童生命末期醫療照護現況；2.安寧緩和療護的使用情形；並進一步探討3.癌症病童人口學與疾病特性、安寧緩和療護使用情形與其生命末期照護情形的相關性。 研究方法： 採回溯性病歷回顧，收集癌症病童生命末期醫療照護相關資料，研究對象為2010年1月至2012年12月間，於台北市某醫學中心兒童血液腫瘤科治療並於此醫學中心死亡之癌症病童，其初診斷年齡小於18歲，死亡年齡可能大於18歲。共有67名研究樣本。 研究工具： 採用自擬之記錄表格，內容共八大項，分別為：病童及家庭基本資料、疾病資料、最後一次住院及死亡相關資料、生命最後一個月醫療照護、死亡前24小時醫療資源使用情形、CPR情形、DNR簽署情形，及安寧緩和療護使用情形。資料經整理編碼後，使用SPSS 18.0統計軟體進行統計分析。 研究結果： 67位研究樣本中，男童佔56.7%（40位），家中獨生子女佔16.4%（11位），診斷為白血病/淋巴癌佔56.7%（38位）。平均診斷年齡為8.50±5.23歲，平均死亡年齡為11.75±5.70歲。 癌症病童在生命末期階段經歷了長時間的住院治療並接受了許多過度醫療。91%（61位）的研究樣本在死亡前三十天內住院天數大於14天，43.3%（29位）的癌症病童在死亡前三十天內有住入加護病房的紀錄，34.3%（23位）於加護病房過世。16.4%（11位）的癌症病童在死亡前三十天內曾接受新的化學治療，34.3%（23位）在死亡前十四天內有接受化學治療。34.3%（23位）在死亡前24小時內有使用氣管內插管及呼吸器，35.8%（24位）有使用強心劑，13.4%（9位）在死亡前三天內曾接受心肺復甦術。 與過去研究相比，癌症病童使用安寧緩和療護的比例有提升，但照會時機仍較晚。本研究所有樣本的安寧照會率為56.7%、安寧涵蓋率為40.3%，照會日期的中位數為死亡前 36.5天，21%在死亡前七天內初次照會。在DNR簽署方面，94%（63位）的研究樣本在死亡前有簽署DNR同意書/意願書的紀錄，但簽屬時機較晚。簽署日期至死亡日期中位數為4.5天，18.3%（11位）在死亡當天才簽，33.3%（21位）在簽署時已插氣管內管。 死亡年齡大於12歲且診斷為白血病/淋巴癌的癌症病童，在末期照護上與其他樣本有較大差異。這組樣本於加護病房死亡的比例顯著較高（p<0.05），死亡前24小時內接受氣管內插管、使用抗生素和強心劑的比例顯著較高（p<0.05），而DNR的簽署時間則較晚，簽署前已接受氣管內插管的比例顯著較高（p<0.01）。 安寧緩和療護的使用情形與生命末期照護有相關性。死亡前曾接受安寧共同照護者，在簽署DNR的時間顯著較早（p<0.01），於加護病房死亡的比例顯著較低（p<0.01），死亡前24小時內接受氣管內插管和強心劑的比例顯著較低（p<0.01），使用鴉片類止痛藥物的比例顯著較高（p<0.01）。 討論與臨床應用： 安寧緩和療護使用情形與癌症病童生命末期照護情形有相關性。臨床醫護人員若能在適當時機照會安寧共同照護團隊，及早與癌症病童及家屬討論臨終醫療決策，能降低癌症病童在生命末期接受過度醫療使用的情形。

Background and Purposes: Childhood cancer is one of leading causes of death in children and adolescents. Cancer children received aggressive treatments near the end of life. This study aimed to explore the end-of-life care and the use of palliative care among cancer children in Taiwan, and to explore the correlation between the characteristics of cancer children, the use of palliative care and the end-of-life care. Methods: A retrospective chart review was conducted. All subjects were diagnosed of cancer under 18, and died between January 2010 to December 2012 in a medical center in Taipei. The total valid sample size was 67. Measurement: The data were collected by a self-developed structured form, which included: (1) patient and family characteristics, (2) oncology summary, (3) information of last hospitalization, (4) aggressiveness of cancer care near the end of life, (5) medical use in the last 24 hours of life, (6) CPR status, (7) DNR status, and (8) the use of palliative care. The data were analyzed by the Software SPSS 18.0. Results: In 67 study subjects, 56.7% were male, 16.4% were single child, 56.7% were diagnosed of leukemia/lymphoma. The average age of diagnosis was 8.50±5.23, and the average age of death was 11.75±5.70. Cancer children experienced long-term hospitalization and aggressive treatments near the end of life. 91% were hospitalized more than 14 days in the last 30 days of life. 43.3% were admitted to ICU in the last 30 days of life, and 34.3% were died in ICU. 16.4% received new chemotherapy in the last 30 days of life, and 34.3% received chemotherapy within 14 days before death. 35.8% received inotropic agents in the last 24 hours of life, and 13.4% received cardiac pulmonary resuscitation within 3 days before death. Although the use of palliative care is increasing, the referral timing was still late. In all subjects, 56.7% received hospice consultation before death, and 40.3% received hospice shared care. The average days of first hospice consultation to death was 50.61±54.83 days (median: 36.5 days), and 21% received first hospice consultation within 7 days before death. DNR permits completed 27.85±56.8 days prior to death (median:4.5 days), and 18.3% completed at the same day of death. Patients who were diagnosed of leukemia/lymphoma and died at the age above 12, are more likely to receive aggressive treatments near the end-of-life than other subjects. They were more likely to die in ICU (p<0.05), and were more likely to use ventilators, antibiotics and inotropic agents within the last 24hours of life. Relationship exists between the usage of palliative care and the end-of-life care of cancer children. Patients who had received hospice shared care were less likely to die in the ICU (p<0.01), and had a lower rate of the use of ventilator and inotropic agents within the last 24 hours of life (p<0.01). The DNR orders were completed earlier in the patients received hospice shared care (p<0.01). Conclusions and Nursing Applications: Relationship exists between the usage of palliative care and the end-of-life care of cancer children. Clinical health providers should consult hospice/palliative care team and conduct palliative discussion with patients and family at a proper time, to improve the end-of-life care for cancer children.