背景：護理之家老年住民經心肺復甦術後之存活率極低，預先選擇不施行心肺復甦術，可避免無效的心肺復甦術所造成的嚴重殘障與痛苦死亡，更有助於減少不必要的醫療耗費。
目的：了解護理之家住民與其家屬使用不施行心肺復甦術決策的現況，以及探索影響此決策之相關因素。
方法：採橫斷式研究設計，研究對象為高雄地區評鑑優等護理之家住民與其代理家屬，資料以病歷回顧與問卷調查方式收集，測量住民、家屬與機構特質以及有無不施行心肺復甦術決策，並以邏輯式迴歸分析各項特質與不施行心肺復甦術決策的相關性。
結果：本研究總收案護理之家住民201位，其中只有33位(16.4%)具不施行心肺復甦術決策，且91%之決策由家屬所簽署。使用多變項邏輯式迴歸分析後，與護理之家住民不施行心肺復甦術決策相關的因素有住民年齡(勝算比[OR]=1.06, 95%信賴區間[C.I]:1.01-1.12)、認知功能(OR=0.91, 95%C.I: 0.85-0.97)、家屬曾與醫師討論不施行心肺復甦術(OR=4.01, 95%C.I: 1.53-10.96)和護理之家具有不施行心肺復甦術政策(OR=17.71, 95% C.I : 5.87-53.46)。
結論：台灣護理之家住民簽署不施行心肺復甦術決策的比率較西方國家低，此結果與台灣文化背景及立法規範可能有關。相關教育課程因此應針對大眾與醫事人員進行預立不施行心肺復甦術決策宣導，而政策規劃更需考量將護理之家不施行心肺復甦術政策加入評鑑標準或法令規範。未來若有研究進一步探討住民與家屬對不施行心肺復甦術決策的看法、需求與決策過程，將有助提供此一衰弱之老年族群生命末期更適切有品質的照顧。

Background & Objectives: Do-not-resuscitate (DNR) decision made in advance for nursing home (NH) residents is believed to prevent futile cardiopulmonary resuscitation and provide end-of-life care with quality. The aims of this study is to report the prevalence of DNR decisions among NH residents and to explore factors associated with DNR decisions in Taiwan.
Methods: We conducted a cross-sectional study in the Kaohsiung area and recruited NH residents and their family surrogates. Information was collected by chart review and questionnaire survey. We assessed the associations between characteristics of resident, family surrogate and NH facility and DNR decision using logistic regression.
Results: Of the 201 NH residents studied, 33 residents (16.4%) had DNR decisions, and family surrogates made 91% of the decisions. Only one of the seven studied NHs had a DNR policy. In multi-variate logistic regression, factors associated with DNR decision were age (odds ratio [OR] =1.06, 95% confidence interval [C.I]:1.01-1.12) and cognitive function (OR =0.91, 95% C.I: 0.85-0.97) of the resident, surrogates’ prior discussion of DNR with physicians (OR =4.01, 95% C.I: 1.53-10.96) and NH with a DNR policy (OR =17.71, 95% C.I : 5.87-53.46).
Conclusions: The prevalence of DNR decisions among Taiwanese NH residents was low, which might result from the culture background and legislation. The lack of DNR policy in most nursing homes suggests a scope for policy development. Additional investigation addressing issues of DNR decision and the decision-making process in residents and family surrogate in Taiwan is worthwhile to achieve better understanding of end-of-life care preference of this frail population.

參考文獻

內政部統計處(2009)。我國生命表。民98年5月17日取自 http://www.moi.gov.tw/stat/life.aspx
內政部統計資訊服務網(2008)。96年底老人長期照護、養護及安養機構概況。 民97年5月7日取自http://www.moi.gov.tw/stat/
台灣安寧緩和醫學會(2007)。安寧緩和醫療：理論與實務。台北：新文京開發。
台灣長期照護專業協會(2008)。認識台灣長期照護服務模式。民97年2月10日取自http://www.ltcpa.org.tw/public/choose_01.html
行政院主計處(2009)。全國人口統計資料。民98年6月15日取自 http://sowf.moi.gov.tw/stat/month/m1-06.xls
行政院經濟建設委員會(2008)。中華民國臺灣97年至145年人口推計。民97年5月7日取自http://www.cepd.gov.tw/m1.aspx
護理人員法(2007)。行政院衛生署衛生法規資料檢索。民97年2月10日取自http://dohlaw.doh.gov.tw/Chi/FLAW/FLAWDAT01.asp
行政院衛生署統計公佈欄 (2008)。96年醫療機構及其他醫事機構概況。 民97年9月17日取自http://www.doh.gov.tw/CHT2006/DM/DM2_2.aspx?now_fod_list_no=10306&class_no=440&level_no=4
李世代(2003)。老年醫學(一)老年照護與老化之一般原則。台北：台灣老年醫學會。
李偉立(2000)。醫院附設與獨立型護理之家住民特質與健康狀況之比較。高雄醫學大學公共衛生學研究所碩士論文。
辛幸珍(2006)。終結台灣社會老年人臨死前使用高科技醫療維生之「慣例」: 探討台灣老年人之生死態度並與紐西蘭及日本老人做比較。發表於健康照護之生命倫理國際研討會。
金桐、吳怡芬、馮家齊、周旻瑄 (1999)。老人長期照護機構設立標準及護理之家設置標準之比較。社區發展季刊，87，254-263。
陳仁熙、宋基幹、高振益、劉海英(2002)。The outcomes of CPR in Cancer Patients CGMH experience。發表於林口長庚紀念醫院全院會議。
陳宇菁(2007)。加護病房家屬代理病人的DNR決策。國立台北護理學院護理研究所碩士論文。
黃錦鳳(2006)。加護病房重症病人簽署不予急救同意書對醫療處置之影響。臺北醫學大學護理學研究所碩士論文。
葉莉莉、田玫、溫敏杰、陳惠姿(2000)。護理之家住民功能狀態探討。社區發展季刊，92，359-369。
鄒海月、王守容、何裕芳(1999)。癌症末期病患家屬對不予急救之態度及其相關因素之初探。榮總護理，16(4)，344-356。
趙耿裕 (2007)。護理之家住民非計畫性轉住院之研究—以南部四家護理之家為例。屏東美和技術學院健康照護研究所碩士論文。
劉淑娟(2007)。長期照護。台北：華杏。
蔡甫昌(2004)。臨床生命倫理學。台北：財團法人醫院評鑑暨醫療品質策進會。
蔡甫昌(2006)。重症加護病患照護之倫理議題。當代醫學，10，105-114。
蔡哲宏(2006)。急救之倫理議題。澄清醫護管理雜誌，2(2)，4-8。
醫政處(2002)。安寧緩和醫療條例，華總一義字第八九零零一三五零八零號令公佈。
Adams, D. H., & Snedden, D. P. (2006). How misconceptions among elderly patients regarding survival outcomes of inpatient cardiopulmonary resuscitation affect do-not-resuscitate orders. J Am Osteopath Assoc, 106(7), 402-404.
Agard, A., Hermeren, G., & Herlitz, J. (2000). Should cardiopulmonary resuscitation be performed on patients with heart failure? The role of the patient in the decision-making process. J Intern Med, 248(4), 279-286.
AHA. (1974). Standards and guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC): MEdicolegal considerations and recommandations. JAMA, 227(Supp), 864-866.
Applebaum, G. E., King, J. E., & Finucane, T. E. (1990). The outcome of CPR initiated in nursing homes. J Am Geriatr Soc, 38(3), 197-200.
Azoulay, E., Pochard, F., Kentish-Barnes, N., Chevret, S., Aboab, J., Adrie, C., et al. (2005). Risk of post-traumatic stress symptoms in family members of intensive care unit patients. Am J Respir Crit Care Med, 171(9), 987-994.
Batchelor, A. J., Winsemius, D., O'Connor, P. J., & Wetle, T. (1992). Predictors of advance directive restrictiveness and compliance with institutional policy in a long-term-care facility. J Am Geriatr Soc, 40(7), 679-684.
Bedell, S. E., Delbanco, T. L., Cook, E. F., & Epstein, F. H. (1983). Survival after cardiopulmonary resuscitation in the hospital. N Engl J Med, 309(10), 569-576.
Berlowitz, D. R., Wilking, S. V., & Moskowitz, M. A. (1991). Do-not-resuscitate orders at a chronic care hospital. J Am Geriatr Soc, 39(5), 472-476.
Brown, M., Grbich, C., Maddocks, I., Parker, D., Connellan, P. R., & Willis, E. (2005). Documenting end of life decisions in residential aged care facilities in South Australia. Aust N Z J Public Health, 29(1), 85-90.
Burns, J. P., Edwards, J., Johnson, J., Cassem, N. H., & Truog, R. D. (2003). Do-not-resuscitate order after 25 years. Crit Care Med, 31(5), 1543-1550.
Chao, C. S. (2002). Physicians attitudes toward DNR of terminally ill cancer patients in Taiwan. J Nurs Res, 10(3), 161-167.
Cheng, S. Y., Hu, W. Y., Liu, W. J., Yao, C. A., Chen, C. Y., & Chiu, T. Y. (2008). Good death study of elderly patients with terminal cancer in Taiwan. Palliat Med, 22(5), 626-632.
Cooper, S., Janghorbani, M., & Cooper, G. (2006). A decade of in-hospital resuscitation: outcomes and prediction of survival? Resuscitation, 68(2), 231-237.
Diem, S. J., Lantos, J. D., & Tulsky, J. A. (1996). Cardiopulmonary resuscitation on television. Miracles and misinformation. N Engl J Med, 334(24), 1578-1582.
Dobalian, A. (2006). Advance care planning documents in nursing facilities: results from a nationally representative survey. Arch Gerontol Geriatr, 43(2), 193-212.
Eachempati, S. R., Hydo, L., Shou, J., & Barie, P. S. (2006). Sex differences in creation of do-not-resuscitate orders for critically ill elderly patients following emergency surgery. J Trauma, 60(1), 193-197; discussion 197-198.
Eggar, R., Spencer, A., Anderson, D., & Hiller, L. (2002). Views of elderly patients on cardiopulmonary resuscitation before and after treatment for depression. Int J Geriatr Psychiatry, 17(2), 170-174.
Fader, A. M., Gambert, S. R., Nash, M., Gupta, K. L., & Escher, J. (1989). Implementing a "Do-Not-Resuscitate" (DNR) policy in a nursing home. J Am Geriatr Soc, 37(6), 544-548.
Folstein, M. F., Folstein, S. E., & McHugh, P. R. (1975). "Mini-mental state". A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res, 12(3), 189-198.
Frank, C., Heyland, D. K., Chen, B., Farquhar, D., Myers, K., & Iwaasa, K. (2003). Determining resuscitation preferences of elderly inpatients: a review of the literature. CMAJ, 169(8), 795-799.
Ghusn, H. F., Teasdale, T. A., Pepe, P. E., & Ginger, V. F. (1995). Older nursing home residents have a cardiac arrest survival rate similar to that of older persons living in the community. J Am Geriatr Soc, 43(5), 520-527.
Gordon, M. (2001). In long-term care, the "R" in CPR is not for resurrection. Ann R Coll Physicians Surg Can, 34(7), 441-443.
Gordon, M., & Schwartz, B. E. (1996). Do-not-resuscitate practice, guidelines and policies in long-term care in Ontario: results of a survey. Ann R Coll Physicians Surg Can, 29(6), 332-335.
Granger, C. V., Albrecht, G. L., & Hamilton, B. B. (1979). Outcome of comprehensive medical rehabilitation: measurement by PULSES profile and the Barthel Index. Arch Phys Med Rehabil, 60(4), 145-154.
Handy, C. M., Sulmasy, D. P., Merkel, C. K., & Ury, W. A. (2008). The surrogate's experience in authorizing a do not resuscitate order. Palliat Support Care, 6(1), 13-19.
Hashimoto, Y., Moriya, F., & Furumiya, J. (2007). Forensic aspects of complications resulting from cardiopulmonary resuscitation. Leg Med (Tokyo), 9(2), 94-99.
Herlitz, J., Eek, M., Engdahl, J., Holmberg, M., & Holmberg, S. (2003). Factors at resuscitation and outcome among patients suffering from out of hospital cardiac arrest in relation to age. Resuscitation, 58(3), 309-317.
Hershey, C. O., & Fisher, L. (1982). Why outcome of cardiopulmonary resuscitation in general wards is poor. Lancet, 1(8262), 31-34.
Heyland, D. K., Frank, C., Groll, D., Pichora, D., Dodek, P., Rocker, G., et al. (2006). Understanding cardiopulmonary resuscitation decision making: perspectives of seriously ill hospitalized patients and family members. Chest, 130(2), 419-428.
Hiltunen, E. F., Medich, C., Chase, S., Peterson, L., & Forrow, L. (1999). Family decision making for end-of-life treatment: the SUPPORT nurse narratives. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments. J Clin Ethics, 10(2), 126-134.
Hirakawa, Y., Masuda, Y., Kuzuya, M., Iguchi, A., & Uemura, K. (2007). [Decision-making factors regarding resuscitate and hospitalize orders by families of elderly persons on admission to a Japanese long-term care hospital]. Nippon Ronen Igakkai Zasshi, 44(4), 497-502.
Hsin, C. H., & Darry, M. (2006). Comparisons of life image and end-of-life attitudes between the elderly in Taiwan and New Zealand. Journal of nursing research, 14(3), 198-208.
Huang, C. H., Chen, W. J., Ma, M. H., Chang, W. T., Lai, C. L., & Lee, Y. T. (2002). Factors influencing the outcomes after in-hospital resuscitation in Taiwan. Resuscitation, 53(3), 265-270.
Huang, C. H., Hu, W. Y., Chiu, T. Y., & Chen, C. Y. (2008). The practicalities of terminally ill patients signing their own DNR orders--a study in Taiwan. J Med Ethics, 34(5), 336-340.
Hui, E., Ho, S. C., Tsang, J., Lee, S. H., & Woo, J. (1997). Attitudes toward life-sustaining treatment of older persons in Hong Kong. J Am Geriatr Soc, 45(10), 1232-1236.
Kellogg, F. R., & Ramos, A. (1995). Code status decision-making in a nursing home population: processes and outcomes. J Am Geriatr Soc, 43(2), 113-121.
Kim, C., Becker, L., & Eisenberg, M. S. (2000). Out-of-hospital cardiac arrest in octogenarians and nonagenarians. Arch Intern Med, 160(22), 3439-3443.
Kim, S. Y., Karlawish, J. H., & Caine, E. D. (2002). Current state of research on decision-making competence of cognitively impaired elderly persons. Am J Geriatr Psychiatry, 10(2), 151-165.
Kouwenhoven, W. B., Jude, J. R., & Knickerbocker, G. G. (1960). Closed-chest cardiac massage. JAMA, 173, 1064-1067.
Laakkonen, M. L., Pitkala, K. H., Strandberg, T. E., Berglind, S., & Tilvis, R. S. (2005). Older people's reasoning for resuscitation preferences and their role in the decision-making process. Resuscitation, 65(2), 165-171.
Layson, R. T., Adelman, H. M., Wallach, P. M., Pfieifer, M. P., Johnson, S., & McNutt, R. A. (1994). Discussions bout the use of life-sustaining treatments: a literature review of physicians' and patients' attitudes and practices. J Clin Ethics, 5(3), 195-203.
Levin, J. R., Wenger, N. S., Ouslander, J. G., Zellman, G., Schnelle, J. F., Buchanan, J. L., et al. (1999). Life-sustaining treatment decisions for nursing home residents: who discusses, who decides and what is decided? J Am Geriatr Soc, 47(1), 82-87.
Levy, C. R., Fish, R., & Kramer, A. (2005). Do-not-resuscitate and do-not-hospitalize directives of persons admitted to skilled nursing facilities under the Medicare benefit. J Am Geriatr Soc, 53(12), 2060-2068.
Liu, J. M., Lin, W. C., Chen, Y. M., Wu, H. W., Yao, N. S., Chen, L. T., et al. (1999). The status of the do-not-resuscitate order in Chinese clinical trial patients in a cancer centre. J Med Ethics, 25(4), 309-314.
Liu, L., & Tinker, A. (2001). Factors associated with nursing home entry for older people in Taiwan, Republic of China. Journal of interprofessional care, 15(3), 245-255.
Lwanga, S. K., & Lemeshow, S. (1996-98). Sample Size Determination in Health Studies: World Health Organization..
Mahoney, F. I., & Barthel, D. W. (1965). FUNCTIONAL EVALUATION: THE BARTHEL INDEX. Md State Med J, 14, 61-65.
Mark, D. H., Bahr, J., Duthie, E. H., & Tresch, D. D. (1995). Characteristics of residents with do-not-resuscitate orders in nursing homes. Arch Fam Med, 4(5), 463-467.
Marks, M. A., & Arkes, H. R. (2008). Patient and surrogate disagreement in end-of-life decisions: can surrogates accurately predict patients' preferences? Med Decis Making, 28(4), 524-531.
Messinger-Rapport, B. J., & Kamel, H. K. (2005). Predictors of do not resuscitate orders in the nursing home. J Am Med Dir Assoc, 6(1), 18-21.
Mohr, M., Bomelburg, K., & Bahr, J. (2001). [Attempted CPR in nursing homes - life-saving at the end of life?]. Anasthesiol Intensivmed Notfallmed Schmerzther, 36(9), 566-572.
Murphy, D. J., Burrows, D., Santilli, S., Kemp, A. W., Tenner, S., Kreling, B., et al. (1994). The influence of the probability of survival on patients' preferences regarding cardiopulmonary resuscitation. N Engl J Med, 330(8), 545-549.
Murphy, D. J., Murray, A. M., Robinson, B. E., & Campion, E. W. (1989). Outcomes of cardiopulmonary resuscitation in the elderly. Ann Intern Med, 111(3), 199-205.
O'Brien, L. A., Grisso, J. A., Maislin, G., LaPann, K., Krotki, K. P., Greco, P. J., et al. (1995). Nursing home residents' preferences for life-sustaining treatments. JAMA, 274(22), 1775-1779.
O'Connor, D. W., Pollitt, P. A., Hyde, J. B., Fellows, J. L., Miller, N. D., Brook, C. P., et al. (1989). The reliability and validity of the Mini-Mental State in a British community survey. J Psychiatr Res, 23(1), 87-96.
O'Donnell, H., Phillips, R. S., Wenger, N., Teno, J., Davis, R. B., & Hamel, M. B. (2003). Preferences for cardiopulmonary resuscitation among patients 80 years or older: the views of patients and their physicians. J Am Med Dir Assoc, 4(3), 139-144.
Oliver, D. P., Porock, D., & Zweig, S. (2005). End-of-life care in U.S. nursing homes: a review of the evidence. J Am Med Dir Assoc, 6(3 Suppl), S21-30.
Peatfield, R., Sillett, R., Taylor, D., & McNicol, M. (1977). Survival after cardiac arrest in hospital. Lancet, 1, 1223-1225.
Reilly, B. M., Magnussen, C. R., Ross, J., Ash, J., Papa, L., & Wagner, M. (1994). Can we talk? Inpatient discussions about advance directives in a community hospital. Attending physicians' attitudes, their inpatients' wishes, and reported experience. Arch Intern Med, 154(20), 2299-2308.
Sandroni, C., Nolan, J., Cavallaro, F., & Antonelli, M. (2007). In-hospital cardiac arrest: incidence, prognosis and possible measures to improve survival. Intensive Care Med, 33(2), 237-245.
Saunders, J. (2001). Perspectives on CPR: resuscitation or resurrection? Clinical Medicine, Journal of the Royal College of Physicians, 1, 457-460.
Seymour, J., Gott, M., Bellamy, G., Ahmedzai, S. H., & Clark, D. (2004). Planning for the end of life: the views of older people about advance care statements. Soc Sci Med, 59(1), 57-68.
Shah, M. N., Fairbanks, R. J., & Lerner, E. B. (2007). Cardiac arrests in skilled nursing facilities: continuing room for improvement? J Am Med Dir Assoc, 8(3 Suppl 2), e27-31.
Shalowitz, D. I., Garrett-Mayer, E., & Wendler, D. (2006). The accuracy of surrogate decision makers: a systematic review. Arch Intern Med, 166(5), 493-497.
Sheehan, D. K., & Schirm, V. (2003). End-of-life care of older adults. Am J Nurs, 103(11), 48-51, 54-48; quiz 59.
Smith, T. J., Desch, C. E., Hackney, M. H., & Shaw, J. E. (1997). How long does it take to get a "do not resuscitate" order? J Palliat Care, 13(1), 5-8.
Sulmasy, D. P., Sood, J. R., Texiera, K., McAuley, R. L., McGugins, J., & Ury, W. A. (2006). A Prospective Trial of a New Policy Eliminating Signed Consent for Do Not Resuscitate Orders. J Gen Intern Med, 21(12), 1261-1268. .
Talbott, J. H., Jude, J. R., & O., E. J. (1965). Fundamentals of cardiopulmonary resuscitation. Philadelphia: F. A. Davis.
Tang, S. T., Liu, T. W., Lai, M. S., Liu, L. N., & Chen, C. H. (2005). Concordance of preferences for end-of-life care between terminally ill cancer patients and their family caregivers in Taiwan. J Pain Symptom Manage, 30(6), 510-518.
Teno, J. M., Branco, K. J., Mor, V., Phillips, C. D., Hawes, C., Morris, J., et al. (1997). Changes in advance care planning in nursing homes before and after the patient Self-Determination Act: report of a 10-state survey. J Am Geriatr Soc, 45(8), 939-944.
Tresch, D. D., Neahring, J. M., Duthie, E. H., Mark, D. H., Kartes, S. K., & Aufderheide, T. P. (1993). Outcomes of cardiopulmonary resuscitation in nursing homes: can we predict who will benefit? Am J Med, 95(2), 123-130.
Vig, E. K., Starks, H., Taylor, J. S., Hopley, E. K., & Fryer-Edwards, K. (2007). Surviving surrogate decision-making: what helps and hampers the experience of making medical decisions for others. J Gen Intern Med, 22(9), 1274-1279.
Wallace, S. K., Ewer, M. S., Price, K. J., & Feeley, T. W. (2002). Outcome and cost implications of cardiopulmonary resuscitation in the medical intensive care unit of a comprehensive cancer center. Support Care Cancer, 10(5), 425-429.
Zweig, S. C., Kruse, R. L., Binder, E. F., Szafara, K. L., & Mehr, D. R. (2004). Effect of do-not-resuscitate orders on hospitalization of nursing home residents evaluated for lower respiratory infections. J Am Geriatr Soc, 52(1), 51-58.