연명치료 중단에 대한 자기결정권 의식조사

김현정 을지대학교 대학원 2010 국내석사

This study was a narrative research attempted to apply to intervened nursing of patients receiving life-sustaining treatments, and help better social understanding of their decisions for life-sustaining treatments. This study provides basic data for the development of a sustainable and reasonable system by surveying the perception of outpatients, families of inpatients, and doctors on terminally ill patients' decision-making rights to withdrawing life-sustaining treatments. The subjects of this study were 130 each of doctors in general hospitals, outpatients that have visited Internal Medicine, Neurology, and Neurosurgery departments of a general hospital in Seoul, and families of inpatients in Internal Medicine, Neurology, and Neurosurgery departments. The tools of research were the guidelines on withdrawing life-sustaining treatments presented by the National Evidence-based Healthcare Collaborating Agency and a modified version of Yoon Seong Lee's survey on the attitude of withdrawing life-sustaining treatments (2009). The reliability of agreement to the request to withdrawing life-sustaining treatments was Cronbach's ⍺=.885 and the reliability of acceptance of decision-making rights of patients to withdrawing life-sustaining treatments was Cronbach's ⍺=.738. The results were analyzed using the SPSS WIN 12.0 program, whereas the demographic characteristics of subjects were analyzed using technical statistics and the difference in perception of patients' decision-making rights for the withdrawal of life-sustaining treatments using ANOVA. The difference in perception of withdrawing life-sustaining treatments according to demographic characteristics was analyzed using t-test and ANOVA. The reliability of measuring tools was expressed by Cronbach's ⍺ value. The following summarizes the results of this study: First. For the acceptance of terminally ill patients' request to withdrawing life-sustaining treatments, 85.4% of patients, 80.8% of families, and 80.0% of doctors agreed to it. The biggest reason why patients' decision to withdrawing life-sustaining treatments should be respected was ‘because it is meaningless to receive treatments if conditions could not be improved’ Patients (43.7%) and doctors (36.5%) agreed to withdrawing life-sustaining treatments. Families (31.2%) responded the biggest reason is ‘because patients' decision is important.’ On the other hand, patients, families, and doctors responded that the reason why, "Terminally ill patients' request to withdrawing life-sustaining treatments cannot be accepted," is because, "Life cannot be randomly decided by someone." Second. Agreement to terminally ill patients' request to withdrawing life-sustaining treatments was highest for patients (3.94) and families (4.00) in "removing the medical ventilator" and for doctors (4.29) in "Do-Not-Resuscitation(DNR)." Patients were more likely to agree when they had higher education level and better financial conditions. Third. As for the acceptance of terminally ill patients' decision-making rights to withdrawing life-sustaining treatments, patients and families (both 4.12) responded that "It is necessary to enact laws to permit withdrawal of life-sustaining treatments if requested by patient," and doctors (4.37) responded that, "It is necessary to define terminally ill patients that are receiving life-sustaining treatments." In relation to demographic characteristics, patients with higher education level and better financial conditions stressed the importance of patients' decision-making rights. Families that are married and have higher educational level stressed the importance of patients' decision-making rights, whereas doctors stressed it according to age, position, marital status, and experience in prescribing withdrawal of life-sustaining treatments. In summary, patients, families, and doctors believed that terminally ill patients' life-sustaining treatments extend pain and degrade quality of life. With changes in the view of life and death, they believed that such life is meaningless and were positive about the decision to terminate life-sustaining treatments. Therefore, nurses should help patients finish their lives and the withdrawal of terminally ill patients' life-sustaining treatments tends to be socially accepted, and arbitrate difference in opinions of patients, families, and doctors in the process of making the decision to withdrawing life-sustaining treatments. Also, subjective and ethical guidelines as well as laws and systems should be established to stimulate social and governmental responsibilities and to prevent unjust deaths of patients. 본 연구는 회복 불가능한 환자의 연명치료 중단의 환자 자기결정권에 대한 외래 환자와 입원환자 가족 및 의사의 의식을 조사하고 이를 파악함으로써, 연명치료를 받는 환자의 간호중재에 적용하고 연명치료 결정을 위한 사회적 이해를 돕고 체계적이고 합리적인 제도장치가 마련되는데 기초자료를 제시하고자 시도된 서술적 조사연구이다. 연구대상은 종합병원의 의사와 서울 일개 종합병원의 내과, 신경과, 신경외과를 내원하는 외래 환자 및 내과, 신경과, 신경외과 병동에 입원 치료 받고 있는 환자를 돌보는 가족 대상으로 각각 130명씩 실시하였다. 연구도구는 한국보건의료연구원에서 발표한 연명치료 중단에 대한 지침과 이윤성 등(2009)의 연명치료 중단에 대한 태도 조사의 설문을 본 연구에 맞게 수정하여 사용하였다. 무의미한 연명치료 중단 요청에 대한 찬성 정도의 설문 신뢰도는 Cronbach's ⍺=.885이었고, 무의미한 연명치료 중단 결정에 관한 자기결정권 인정 대안의 설문 신뢰도는 Cronbach's ⍺=.738이었다. 수집된 자료는 SPSS WIN 12.0 프로그램을 이용하여 분석하였고, 대상자의 일반적 특성은 기술통계로, 대상자간의 연명치료 중단에 대한 자기 결정권의 의식 차이는 ANOVA로 분석하였다. 일반적 특성에 따른 연명치료 중단에 대한 의식 차이는 t-test와 ANOVA로 분석하였다. 측정도구의 신뢰도 검정은 Cronbach's ⍺계수를 이용하였다. 본 연구 결과는 다음과 같다. 첫째, 회복 불가능한 환자의 연명치료 중단에 대한 환자 요청의 수용에 있어서 환자는 85.4%, 가족은 80.8%, 의사는 80.0%로 찬성하는 것으로 나타났다. 회복 불가능한 환자가 연명치료 중단 요청을 할 경우 존중해야 하는 가장 큰 이유는 ‘회복 불가능한 상태로 더 이상의 치료 의미가 없기 때문’이 환자(43.7%)와 의사(36.5%)에서 가장 높게 나타났고, 가족은 ‘환자의 의사표시가 중요하기 때문’이 31.2%로 높게 나타났다. 반대로 회복 불가능한 환자의 연명치료 중단 요청을 받아들일 수 없다고 생각하는 이유로써 대상자인 환자, 가족, 의사 모두가 ‘생명을 인간 임의로 결정할 수 없는 것이기 때문’인 것으로 조사되었다. 둘째, 치료내용에 따른 회복 불가능한 환자의 연명치료 중단 요청에 대한 찬성 정도를 보면 ‘인공호흡기의 장치 제거’ 항목에서 환자는 평균 3.94, 가족은 평균 4.00으로 가장 높았고, 의사는 ‘심폐소생술 금지’ 항목에서 평균 4.29로 높게 나왔다. 환자는 교육정도가 고학력일수록, 경제상태가 높을수록 적극적인 찬성의 태도를 보였다. 셋째, 회복 불가능한 환자의 연명치료 중단 결정에 관한 자기결정권의 인정방안에서 환자와 가족은 ‘환자 결정에 따른 연명치료 중단을 허용하는 법률 제정이 필요하다’가 각각 평균 4.12로 가장 높았고, 의사는 ‘연명치료 중단 대상자인 회복 불가능한 환자의 정의가 필요하다’가 평균 4.37로 가장 높았다. 일반적 특성에서 보면 환자는 교육정도가 고학력일수록, 경제상태가 높을수록 자기결정권의 인정 방안에 대한 필요성을 강조하였다. 가족은 기혼인 경우가 미혼보다, 교육정도가 높을수록 자기결정권의 인정 방안에 대한 필요성을 강조하였고, 의사는 연령과 직위, 결혼 상태, 연명치료 중단 처방경험에 따라 자기결정권의 인정 방안에 대한 필요성을 강조하는 것으로 나타났다. 결과적으로 환자, 가족, 의사 모두가 삶과 죽음에 대한 가치관의 변화로 회복 불가능한 환자의 연명치료가 고통을 연장시키고 삶의 질을 저하시키며, 이러한 삶은 무의미하다고 생각하여 연명치료 중단 결정을 긍정적으로 생각하고 있었다. 따라서 간호사는 회복 불가능한 환자의 연명치료 중단이 사회적으로 받아들여지는 과정에서 환자가 존엄한 존재로 삶을 정리할 수 있도록 하며, 회복 불가능한 환자의 연명치료 중단 결정 과정에서 환자나 가족, 의사 간의 의견 차이를 이해하고 조정하여야 할 것으로 생각한다. 또한 객관적이며 윤리적인 지침이나 사회적 국가적 책임과 음성적인 죽음을 방지하기 위한 법적, 제도적 뒷받침이 정립되는데 함께 노력해야 할 것이다.

연명치료 중단을 결정한 말기환자 가족의 경험

박연옥 연세대학교 대학원 2003 국내박사

본 연구는 말기환자의 연명치료 중단에 대한 가족의 경험을 밝히기 위한 탐색적 연구로 실시되었다. 본 연구의 대상자는 수원 소재 1개 대학병원에 입원치료를 받고 있으며 주치의가 환자의 치료가 더 이상 의미가 없다고 판단하여 연명치료 중단을 결정한 환자의 가족(주간호제공자)이다. 자료수집은 2002년 8월부터 2003년 5월까지 심층면접 방법으로 하였고 내용분석법으로 분석한 결과 6개의 주제와 39개의 경험내용이 도출되었다. 본 연구의 결과는 다음과 같다. 1. 연명치료 중단 결정 시 말기환자 가족의 경험은 연명치료 중단 결정 시기와 연명치료 중단 결정 후로 범주화 되었다. 2. 연명치료 중단 결정시기의 경험에서는 연명치료 중단 결정요인, 결정과정, 결정 참여자가 주제로 도출되었고, 연명치료 중단 결정 후의 경험에서는 치료의 내용, 죽음수용, 예측된 상실반응의 주제가 나타났다. 3. 연명치료 중단 결정요인은 회복 가능성, 고령, 고통경감, 신체 손상, 의식수준, 부담감, 주변의견, 가족의 과거 경험, 환자 본인의 평소 희원이었다. 4. 연명치료 중단 결정과정은, 모두 의사가 먼저 권유하고 이를 가족이 합의하여 수용하였다. 5. 연명치료 중단결정 참여자는 의사와 가족, 친지들로 나타났고, 가족합의 과정에서 환자는 제외되었다. 간호사도 참여하지 않은 것으로 나타났다. 6. 치료의 내용에서는 치료중단 자체에 대한 갈등, 고통경감과 생명단축 사이에서의 갈등, 계속되는 연명치료에 대한 분노, 병원에서의 기본간호에 대해서도 분노, 계속되는 치료를 거부하지 못함이란 경험내용이 나타났다. 7. 치료중단 전후 처치 변화는 없었고, 치료결정에 의사 외에 다른 의료진의 참여나 환자, 가족의 의견은 반영되지 않는 것으로 나타났다. 8. 죽음수용에서는 죽음을 받아들이기까지의 준비기간 필요, 환자 자신이 죽음을 임박했음을 알고 있다고 생각, 환자 자신이 삶의 마무리를 잘 하기 바람, 환자에게 임종준비를 시키지 못함에 대한 죄책감, 고통없이 가기를 바람, 깨끗하게 가기를 바람, 모든 것을 다 소진함, 임종을 위해 가족이 모두 모임, 병원환경 및 면회제도에 대한 바람, 장례준비, 최선을 다 했다는 자기위안, 임종을 위한 의료진의 지지 필요의 경험내용이 나타났다. 9. 예측된 상실반응에서는 예상되는 이별로 인한 초조함, 자식을 앞세운다는 한탄, 환자의 치료 불이행 태도를 원망, 환자에 대한 연민, 자신의 처지 한탄, 지나온 생활을 회고함의 주제가 나타났다. 결론적으로 말기환자의 가족은 회복가능성이 없음을 주된 이유로 연명치료 중단을 결정하고, 의사가 권유한 것을 가족이 수용하는 형태이나 환자는 배제한 채 가족이 결정하였다. 연명치료 중단 결정 전후 치료내용의 변화는 없었고 가족들은 치료의 진행상황을 알지 못한 채 모든 의사결정을 의료진에게 맡기고 있었다. 연명치료를 무의미하다고 생각하나 이를 거부하지 못해 분노하고 갈등하고 있었으며 심지어는 기본 간호도 무의미한 치료로 생각하고 있었다. 가족들은 환자의 죽음을 수용하고는 환자 자신도 죽음이 임박했음을 알고 있다고 생각하면서도 환자와 함께 죽음을 준비하지는 못하였다. 그로 인해 죄책감을 느끼면서도 죽어간다는 말을 하지 못하고, 환자 스스로 죽음을 준비하고 존엄을 지키고 죽어가기를 바라고 있었다. 이러한 일련의 과정에서 가족들은 의료진의 지지와 환자와 가족이 함께 있을 수 있는 임종실과 면회제도를 원하였다. 환자의 죽음을 수용한 후 가족들은 초조함, 한탄, 원망, 죄책감, 자기연민, 회한, 회고 등의 예측된 상실반응을 경험하였다. 따라서 간호사는 연명치료 중단 결정요인, 결정과정, 결정 참여자, 치료의 내용에 대하여 잘 알고 의료팀간에, 환자 및 가족간에 의사소통의 주체가 되어야 한다. 이를 위해 간호사들은 고통완화, 고령, 신체손상을 근거로 연명치료 중단을 조장, 방조하는 일이 발생하지 않도록 감시하되, 환자가 존엄을 지키고 삶에 대한 정리를 하고 죽어갈 수 있도록 하는 옹호자의 역할을 하여야 한다. 간호사는 연명치료 중단 결정시기가 예측된 상실반응이 나타날 수 있는 시기라는 이해를 통해 간호중재를 하여야 하며, 죽음에 대해 환자와 가족이 함께 이야기 할 수 있어야 한다. 환자가 인간의 존엄성과 위엄을 갖추고 죽음을 맞이할 수 있도록 임종실이나 가족실을 운영하고, 말기환자의 무의미한 치료에 드는 비용을 삶의 질을 향상하는데 전환하여 사용할 수 있는 호스피스 간호에 대한 제도적 장치를 마련하여야 한다. 또한 말기환자의 치료의 범위, 치료 중단의 범위 등을 환자, 가족과 협의하여 결정할 수 있어야 한다. 이를 위해 연명치료 중단에 대한 사회적 공감대가 형성되고, 윤리지침이 만들어지고, 법적 보장 위에서 연명치료 중단 규정이나 윤리위원회 등이 운영되어야 한다. This study was designed to identify experiences of family members regarding withdrawing life-sustaining treatment when patients are terminally ill. The exploratory method was employed for the study. The participants were family members of patients, who decided to withdraw life-sustaining treatment. The patients had been admitted to a university hospital located in Suwon and the physician had determined that further treatment was no longer meaningful. Data were collected through in-depth interviews, conducted from August 2002 to May 2003 and analyzed using content analysis. The analysis revealed 6 themes and 39 experiences. The results of the study are as follows: 1. The experiences of family members regarding withdrawal of life-sustaining treatment were categorized in two phases. One was during the decision- making process and the other was after treatment had been withdrawn. 2. From the experiences during the decision-making process, the themes, reason for decision, process of decision and participation in the decision were derived, and after treatment was withdrawn, the themes were type of treatment, acceptance of death and reaction to anticipated loss. 3. The main factors for making a decision to withdraw treatment were related to the possibility of recovery, advanced age, alleviation of pain, wasting of the body, consciousness, burden, recommendation, past experience of family members, and desire of patients. 4. The decision-making process was initially recommended by physicians followed by agreement and acceptance of family members. 5. The participants in the decision-making process were found to be physicians, family members and relatives. Patients were excluded and nurses did not participate. 6. For treatment, themes included conflict about the withdrawal itself, conflict between alleviation of pain and shortening of life, anger against continuous life-sustaining treatment, anger against standard care in the hospital, being unable to refuse continuous treatment. 7. It was found that after treatment was withdrawn, there were no changes in treatment, no participation of other medical staff and no reflection on opinions of family members in decisions concerning treatment. 8. In acceptance of death, the following were found: need for time to admit to possibility of death, thinking that the patients themselves were aware of being close to death, hoping that the patients themselves were prepared for their rest of lives, regret for not giving the patients a chance to prepare themselves for death, desire for patient to die with no pain, desire for patient to die with dignity, thinking that all treatment had been tried, all family members being present at death, asking for better hospital environment and visiting systems, preparing for the funeral, self-consolation at having done the best, requirement of physicians' assistance at death. 9. In reaction to anticipated loss, the following were found: impatience in the anticipated loss, grief for letting their children pass away in advance, regret for stopping medical treatment, compassion for the patient, regret for their position, and looking back over their past. In conclusion, the pattern in decisions to withdraw life-sustaining treatment from terminally ill patients were mainly made because no possibilities of recovery were anticipated by physicians, followed by acceptance and decision by family members but with no participation by the patients themselves. Before and after withdrawing treatment, there were no changes in medical treatment and no information about phases of medical treatment. All decision-making was left to physicians. The families were angry about being unable to refuse life-sustaining treatment regarded as meaningless. Moreover they thought even standard nursing was meaningless. After admitting that death was a possibility, family members regretted that they were unable to prepare for death together with patient even though they thought the patients themselves knew death was coming soon. Nevertheless family members hoped that the patients could prepare for death by themselves and die with dignity. After acceptance of the decision, family members experienced a reaction to the anticipated loss such as impatience, sighing, grievance, guilt, self-pity, regret, and the need for reflection. With such sentiments, family members required support from physicians and required a family room where family members could stay with their patients. Therefore, nurses need to be aware of main reasons for withdrawing life-sustaining treatment, the decision-making process, participants in decision-making and the scope of medical care. They need to be central in assuring communication among medical team, patients and family members. Nurses need to monitor so that deciding to withdraw life-sustaining treatment may not be promoted or assisted only for the reasons such as alleviation of pain, being advanced age, and wasting of the body. And, on the other, hand nurses need to be advocates who can help dying patients settle issues in their lives and die with dignity. Nurses need to monitor nursing care, understand that a reaction to anticipated loss can show up at when the decision to withdraw life-sustaining treatment is made and also enable patients and family members to talk together about death. Provision of a room for the family is required so that patients may face death with dignity. Regulations for hospice care are required so money is not used for meaningless medical treatment but in meeting the needs for improving quality of life. The scope of medical treatment to be continued or withdrawn should be decided after discussion with family members. Social consensus on withdrawing life-sustaining treatment needs to be developed, ethical guidelines stipulated and, under the protection of law and regulations, a regulatory system for withdrawing life-sustaining treatment.

생애 말기 연명의료결정에 관한 연구 : 함께하는 의사결정의 가능성 탐색

최지연 연세대학교 대학원 2021 국내박사

Since the implementation of the Act on Decisions on Life-Sustaining Treatment for Patients in Hospice and Palliative Care or at the End of Life (LSTD Act), Korea has been realizing a medical decision-making process that reflects patients' preferences and intentions. The LSTD Act is for dying patients and identifies their intention to avail life-sustaining treatment. The patient's intention may be expressed as confirming the contents of the Physician Order for Life-sustaining Treatment (POLST), written by the doctor and advanced directive (AD), previously written by the patient. If the doctor is unable to confirm the patient's intention due to a lack of decision-making ability, the doctor receives a statement from two or more of the patient's family members about their willingness to stop life-sustaining treatment. If the patient does not mention anything about his/her life, the doctor may seek consent from all family members and suspend the patient's life-sustaining treatment. Therefore, the LSTD Act method can be categorized into patients and families, according to the subject of the decision. In addition, the law prioritizes checking the patient's intention by presenting the method of verification sequentially. Considering the current status of the LSTD Act, implemented three years ago, it was much more often according to the family's decision rather than the patient's intention. The LSTD Act is designed to protect patients' right to self-determination, but decisions continue to be made by families instead of patients. This is not consistent with the recent theory of end-of-life decision-making and shared decision-making (SDM). This study determines theoretical facts through a literature review of end-of-life decision-making, which is represented by life-sustaining medical decisions, reflects them in clinical sites, identifies problems, and offers strategies to improve them. This study can be performed in two ways. Through an integrated literature review of13 published studies, we found elements of SDM. A qualitative descriptivestudy was also conducted to confirm the experience of life-sustaining medical decisions. Qualitative descriptive research collected data by conducting in-depth interviews with ten medical staff members from a medical institution with experience in the LSTD system. The data were analyzed according to traditional content analysis methods, and the results of the study were derived. The findings of this study are also two-fold: There are five elements of SDM found in an integrated literature review. (1) SDM should form a partnership between participants. Patients should actively participate in decision-making and have an equal relationship between patients and doctors. (2) Information must be exchanged in SDM. During the decision-making process, doctors provide medical information to patients. The doctor must inform the patient of the medical facts deemed necessary for the patient, including the patient's current condition and the expected outcome. The doctors should also provide the advantages and disadvantages of treatment options and options applicable to the patient's condition. Doctors should determine the patient's decision-making ability and understand and utilize patient-decision-aid to make it easier for the patient to understand. Contrarily, the patient should draw up his/her own ideas and communicate with the doctor. The patient's thoughts should be taken into account for his/her preferences, values, and desired attitudes to life after making decisions. A doctor should draw out the patient's thoughts so that the patient can narrate his/her story. In addition, based on the feedback received to the patient, the patient should be informed of the applicable options and the predicted results. (3) SDM goes through due consideration. Patients and physicians should be provided sufficient time to undergo repeated convergence in the decision-making process. In addition, decision-making participants can be expanded depending on the patient's request or circumstances. The process of deliberation is aimed at giving time to patients, but experts must be constantly involved. (4) SDM shall be made by the patient and the doctor. Decision-making should follow a sufficient understanding of information. In addition, all decision-making participants must share their decisions. A doctor should formulate a treatment plan after making a decision. (5) SDM requires periodic review and confirmation. After deciding, the doctor shall have the patient review the details of the decision. Doctors also need to periodically ask the patient's intentions and recheck when the condition worsens. Qualitative studies have shown the characteristics of the life-sustaining treatment decision process of a single medical institution and problems arising from this. Medical institutions have made efforts to make decisions together with medical staff, patients, and families during the life-sustaining treatment decision process. The doctor shares information about the patient's mental state or preference for deathbed with other medical staff. They encourage their participation by engaging patients and sharing patient’s condition with their families. The medical staff of A Medical Center provided medical information to the patient and confirmed the patient's information through medical records and family members. During the interview, the doctor identified the anxiety and understanding of the patient and the family and gave them about three days to decide. The characteristics of pursuing the best choice were revealed. However, the decision-making process cited problems with decision-making methods that distorted the nature of the patient-centered nature, as well as general and cultural restrictions in the course of legal processes. However, medical staff at A Medical Center communicated with a focus on outcomes rather than decisions. The decision-making process tended to be led by the patient's doctor and lacked awareness of end of life. The medical team believed that they did not have enough time for deliberation given to the patient and talked about the environment in which they did not have enough time to talk in advance. The medical team also said that intervention was not possible in the conflict, and that the Medical Institution Ethics Committee could not resolve the conflict. Therefore, the medical staff were trying to secure their own safety nets in the case of legal disputes. The medical staff were as conscious of the family, as they were of the patient in the decision-making process. The medical staff responded that the life-sustaining treatment decision-making process was led by the family, not by the patient alone. He also said that patients and their families were passive in understanding the disease. Studies show that there is a gap between the theoretical elements of shared decision-making and the status of life-sustaining treatment decisions at medical institution. To address this gap, this study presents obstacles to the decision-making process at the end of life in terms of medical personnel, legal, and socio-cultural aspects. Medical staff had problems with not having partnerships with patients and one-way communication. This is caused by a lack of education about communication, and medical education needs to be improved to improve awareness. The life-sustaining treatment decision-making method is a problem in which life-sustaining treatment decisions are made at the end of the year and at the end of life, and it is difficult for patients to express their opinions. Since the patient is terminally ill, he/she lacks time for deliberation and cannot be reviewed. The law shall be amended to ensure that life-sustaining treatment decisions are made sooner, as the decision on life-sustaining treatment decisions made at the end of life is likely to turn into formal acts. Finally, the life-sustaining treatment decision-making process is heavily influenced by the family. This is a characteristic of family-centered decisions in Eastern cultures and needs to limit and define the role of families. This study proposes improvement measures to move toward decision-making with the life-sustaining treatment decision process. A decision-making team can be formed to reflect the family-centered culture of Korea and the life-sustaining treatment decision-making law. This is an evolution of the theory in which families participate in the decision-making process at the request of patients. The decision-making team can make decisions together from the beginning, involving patients, family members, nurses in charge of patients, and dedicated personnel of the medical institution ethics committee. In addition, patients should be given a wider range of treatment options by exposing life-sustaining treatment care before making terminal judgments. Finally, medical staff must be trained appropriately for mutual communication. 연명의료결정법이 시행된 이래로 한국은 환자의 선호와 의사가 반영된 생애 말기 의학적 의사결정과정을 실현해나가고 있으며 그 과정에서 함께하는 의사결정의 도입의 필요성이 주장되어 왔다. 그러나 환자의 결정보다 가족에 의한 결정이나 판단에 의존하는 등 연명의료결정과정은 생애 말기 의사결정의 최근 지견인 함께하는 의사결정과 부합되지 않는 현상을 보이고 있다. 본 연구는 연명의료결정으로 대표되는 생애말기 의사결정과정에 함께하는 의사결정 문헌을 통해 이론적 사실을 찾아 임상 현장에 반영하여 장애요인을 확인하고 이를 개선할 수 있는 방안을 제시하는 연구이다. 이를 위해 본 연구는 13편의 국내외 문헌을 대상으로 통합적 문헌고찰을 통하여 함께하는 의사결정의 요소를 찾고, 국내 생애말기 의사결정의 특징을 확인하고자 연명의료결정경험에 대한 질적기술연구를 수행하였다. 질적기술연구는 연명의료결정제도를 수행하고 있는 일 의료기관의 의료인 10명에게 심층면담을 실시하여 자료를 수집하였으며, 전통적 내용분석방법에 따라 분석하여 연구결과를 도출하였다. 본 연구의 결과는 크게 두 가지로 나뉜다. 먼저 함께하는 의사결정 요소 탐색을 위한 통합적 문헌고찰에서는 환자-의사로 대표되는 참여자간 파트너십 형성, 정보의 교류, 충분한 숙고, 의사결정, 주기적인 재검토와 확인의 다섯 요소가 도출되었다. 또한 연명의료결정과 관련하여 의사결정경험을 확인한 질적기술연구에서는 일 의료기관의 연명의료결정과정의 특징과 의사결정과정의 제약이 드러났다. 일 의료기관의 연명의료결정과정은 의료진과 환자, 가족이 함께 결정하고자 하는 노력과 최선의 선택을 추구하고자 하는 특징이 드러났다. 그러나 의사결정과정에서 의료행위에서의 제약과 법제도의 수행과정에서의 제약과 문화적 제약이 언급되었다. 본 연구는 연구결과를 토대로 함께하는 의사결정 관점에서 연명의료결정과정의 장애요인을 의료인 측면, 법률적 측면, 사회문화적 측면으로 제시하였다. 또한 이를 해결하기 위하여 법적 환자-의사 관계를 동등하게 설정하고 양방향적 의사소통을 촉진할 수 있도록 의료인 교육의 필요성, 충분한 숙고의 시간을 제공할 수 있도록 연명의료결정법 상의 개선, 가족중심결정으로 대표되는 한국문화에 특화된 의사결정방식을 제안함으로써 함께하는 의사결정의 적용방안을 제시하였다.

종합병원 간호사의 연명의료중단 역할인식 영향요인

조재정 경희대학교 대학원 2022 국내석사

This descriptive research study was conducted to validate influencing factors of the perception of good death, knowledge of advanced directives, lifesustaining treatment nursing care stress, attitudes of life-sustaining treatment, role perceptions toward withdrawal of life-sustaining treatment, with nurses working at a university hospital in Gyeonggi Province as the study participants. The data used to conduct this study were collected by surveying 102 nurses from a university hospital in Gyeonggi Province from September 20, 2021 to October 25, 2021. The perception of good death was measured using HyeonSook Jeong’s tool, a Korean adaptation of the Concept of Good Death Measure, a measure developed by Schwartz, etc. (2003). The knowledge of advanced directives was measured using a tool re-modified and re-supplemented by Suyeon Seo (2019) based on the Act on Life-Sustaining Treatment Determination, which was originally modified and supplemented by In-hye Kwon (2018) after being developed by Sun-woo Hong and Shin-mi Kim (2013). The lifesustaining treatment nursing care stress was measured using a tool developed by Su-jung Lee and Hye-young Kim (2017). The attitudes of life-sustaining treatment was measured using a tool re-modified and re-supplemented by Sujung Lee and Hye-young Kim(2017), which was originally modified and supplemented by Eun-kyung Byun, etc. (2003) after being developed by Gyesun Park (2000). The role perceptions toward withdrawal of life-sustaining treatment was measured using a tool developed by Eun-kyung Byun, etc. (2003). The collected data of this study was analyzed with descriptive statistics, independent t-test, one-way ANOVA, Scheffe test, Pearson correlation, and multiple linear regression using the SPSS 28.0.1.0 program. The key results of this study are as follows: 1. There were a total of 102 participants with an average age of 30.15 and 85.3% were women. 73.5% were unmarried, and the highest level of education was a bachelor’s degree, making up 84.3%. The average working experience was 7.42 years, and the surgical ward was the largest at 30.4%. 67.6% had no religion. 2. The participants averaged a score of 3.12±0.65 out of 4 on the perception of good death and a score of 10.41±1.31 out of 12 on the knowledge of advanced directives. They averaged a score of 3.82±0.85 out of 5 on the lifesustaining treatment nursing care stress and a score of 3.49±0.40 out of 5 on the attitudes of life-sustaining treatment. They averaged a score of 4.07±0.44 out of 5 on the role perceptions toward withdrawal of life-sustaining treatment. 3. The perception of good death based on the general characteristics of the participants differed significantly depending on age (F=5.03, p=.008), clinical experience (F=4.32, p=.016), marital status (t=-2.954, p=.005), etc. The knowledge of advanced directives differed significantly depending on age (F=7.10, p<.001), clinical experience F=6.22, p=.003), marital status (t=- 2.09, p=.042), etc. The life-sustaining treatment nursing care stress differed significantly depending on age (F=6.23, p=.003), clinical experience (F=7.70, p<.001), gender t=-2.09, p=.049), marital status (t=-2.22, p=.032), department of work (F=3.12, p=.029), etc. The average difference in the attitudes of life-sustaining treatment based on general characteristics was not significant. The role perceptions toward withdrawal of life-sustaining treatment differed significantly depending on age (F=6.83, p=.002), clinical experience (F=11.05, p<.001), marital status (t=-3.16, p=.002), level of education (F=5.26, p=.007), etc. 4. There was a statistically positive correlation between the participants’ perception of good death, life-sustaining treatment nursing care stress, and role perceptions toward withdrawal of life-sustaining treatment. The knowledge of advanced directives showed a positive correlation with the attitudes of life-sustaining treatment, whereas the life-sustaining treatment nursing care stress showed a positive correlation with the role perceptions toward withdrawal of life-sustaining treatment. 5. The multiple linear regression was conducted to examine the factors affecting the participants’role perceptions toward withdrawal of life-sustaining treatment. As a result, the explanatory power of the model was 29.5%(F = 5.620, p <.001), and among the variables of general characteristics, the effect of the level of education (β=.336, p<.001) was statistically significant, and among the key variables, the effect of the perception of good death (β=.233, p=.015) was statistically significant. It was identified through the study that the factors affecting the nurses’role perceptions toward withdrawal of life-sustaining treatment were the level of education and perception of good death. Therefore, including content that raises the perception of good death in educational programs to strengthen nurses’role perceptions toward withdrawal of life-sustaining treatment is encouraged. Moreover, as this study was conducted on a certain group of university hospital nurses, it limits the generalization of the results of the study. Hence, it is anticipated that repeated studies performed on various groups will help in providing professional nursing roles to patients who have either reserved or discontinued life-sustaining treatment. 본 연구는 경기도 소재 일개 대학병원에서 근무하는 간호사를 연구 대상으로 좋은 죽음 인식, 사전연명의료의향서 지식, 연명의료 스트레스, 연명의료 태도, 연명의료 중단 역할인식을 파악하고, 연명의료 중단 역할인식의 영향 요인 검증을 위해 수행된 서술적 조사연구이다. 본 연구 수행에 활용된 자료는 2021년 9월 20일부터 2021년 10월 25일까지 설문조사를 통해 수집되었는데 경기도 소재 일 대학병원에서 근무하는 간호사 102명을 설문 대상으로 하였다. 좋은 죽음 인식은 Schwartz 등(2003)에 의해 개발된 척도인 The Concept of Good Death Measure를 우리 말로 번안한 정현숙(2010)의 도구로 측정하였다. 사전연명의료의향서 지식은 홍선우와 김신미(2013)가 개발 후 권인혜(2018)가 수정, 보완한 도구를 서수연(2019)이 연명의료결정법을 토대로 재차 수정, 보완한 도구로 측정하였다. 연명의료 스트레스는 이수정과 김혜영(2017)이 개발한 도구로 측정하였다. 연명의료 태도는 박계선(2000)이 개발 후 변은경 등(2003)이 수정한 도구를 이수정과 김혜영(2017)이 재차 수정, 보완한 도구로 측정하였다. 연명의료중단 역할인식은 변은경 등(2003)이 개발한 도구로 측정하였다. 본 연구의 수집 자료는 SPSS 28.0.1.0 프로그램을 이용해 기술통계, independent t-test, one-way ANOVA, Scheffè test, Pearson correlation, 다중선형회귀분석으로 분석하였다. 본 연구의 결과는 다음과 같다. 1. 대상자는 총 102명으로 평균 연령은 30.15세이며, 85.3%가 여성이었다. 미혼이 73.5%였으며, 최종학력은 학사가 84.3%으로 가장 많았다. 근무 경력은 평균 7.42년이었으며, 외과계 병동이 30.4%로 가장 많았다. 종교가 없는 경우가 67.6%였다. 2. 대상자의 좋은 죽음 인식은 4점 만점에 평균 3.12±0.65점이며, 사전연명의료의향서 지식은 12점 만점에 평균 10.41±1.31점이었다. 연명의료 스트레스는 5점 만점에 3.82±0.85점이며, 연명의료 태도는 5점 만점에 3.49 ±0.40점이었다. 연명의료중단 역할인식은 5점 만점에 4.07±0.44점이었다. 3. 대상자의 일반적 특성에 따른 좋은 죽음 인식은 연령(F=5.03, p=.008), 임상경력(F=4.32, p=.016), 결혼상태(t=-2.954, p=.005) 등에 따라 유의한 차이가 있었고, 사전연명의료의향서 지식은 연령(F=7.10, p<.001), 임상경력(F=6.22, p=.003), 결혼상태(t=-2.09, p=.042) 등에 따라 유의한 차이가 있었다. 연명의료 스트레스는 연령(F=6.23, p=.003), 임상경력(F=7.70, p<.001), 성별(t=-2.09, p=.049), 결혼상태(t=-2.22, p=.032), 근무부서(F=3.12, p=.029) 등에 따라 유의한 차이가 있었다. 연명의료태도는 일반적 특성에 따른 평균 차이가 유의하지 않았다. 연명의료중단 역할인식은 연령(F=6.83, p=.002), 임상경력(F=11.05, p<.001), 결혼상태(t=-3.16, p=.002), 학력(F=5.26, p=.007) 등에 따라 유의한 차이가 있었다. 4. 대상자의 좋은 죽음 인식, 연명의료 스트레스, 연명의료중단 역할인식과 통계적으로 유의한 정적 상관관계가 있었고, 사전연명의료의향서 지식은 연명의료 태도와 유의한 정적 상관관계가 있었다. 연명의료 스트레스는 연명의료중단 역할인식과 유의한 정적 상관관계가 있었다. 5. 대상자의 연명의료중단 역할인식에 영향을 미치는 요인을 확인하기 위해 다중회귀분석을 시행하였다. 연구결과 모형의 설명력은 29.5%이고(F = 5.620, p <.001), 일반적 특성 변수 중에는 학력(β=.336, p<.001)의 영향이 통계적으로 유의하였으며, 주요 변수들 중에는 좋은 죽음 인식(β=.233, p=.015)의 영향이 통계적으로 유의하였다. 본 연구를 통하여 대학병원 간호사의 연명의료중단 역할인식에 영향을 미치는 요인은 학력과 좋은 죽음 인식이었다. 따라서 간호사의 연명의료중단 역할인식을 강화하기 위한 교육프로그램에 좋은 죽음 인식을 높일 수 있는 콘텐츠를 반드시 포함하기를 권장한다. 아울러 본 연구는 일개 대학병원 간호사를 연구 대상으로 설정해 수행한 연구이므로 일반화하기에는 한계가 있으므로 다양한 집단을 바탕으로 반복연구를 수행해 연명치료 유보 및 중단 환자들에게 전문적인 간호역할을 제공하는데 도움이 될 것으로 기대한다. 주요 개념어: 좋은 죽음 인식. 사전연명의료의향서 지식, 연명의료 스트레스, 연명의료 태도, 연명의료중단 역할인식

중환자실 간호사의 연명의료중단에 대한 역할인식 영향 요인

이정교 원광대학교 대학원 2024 국내석사

Purpose : This study aimed to examine the effects of intensive care unit (ICU) nurses' knowledge about and attitude toward withdrawing life-sustaining treatment, as well as their moral sensitivity and biomedical ethical awareness vis-à-vis their role on withdrawing life-sustaining treatment, thereby providing basic data needed to improve ICU nurses' role perception toward life-sustaining treatment. Methods : This study was a descriptive survey to investigate the effects of ICU nurses' knowledge and attitudes, moral sensitivity, and biomedical ethical awareness on their role perception of withdrawing life-sustaining treatment. Data were collected from nurses working in the ICU of an advanced general hospital in I City who consented to participate in the questionnaire survey. The data collection period was from June 13 to 21, 2023. Of 150 copies of a structured questionnaire that was distributed to the participants, 144 completed questionnaires were collected, and 141 completed questionnaires were used for the final analysis. The collected data was analyzed using SPSS 26.0 to calculate the frequency and percentage or mean and standard deviation, and perform t-tests, ANOVA, Pearson's correlation coefficient, and multiple regression. Results : The results of this study are presented as follows. First, With regard to participants' general and work-related characteristics, the mean age was 29.03±6.60 years and the most common age group was 26∼29 years (53 persons, 37.6%), and the most common sex was female (115 persons, 81.6%). The most common response for the highest academic qualification was undergraduate or higher (116 persons, 82.3%), and the most common marital status was unmarried (114 persons, 80.9%). The most common religion was non-religious (86 persons, 61.6%), and total work experience was most frequently 1∼3 years (55 persons, 39.0%). For experience working in the ICU, the most frequent response was 1∼3 years (63 persons, 44.7%), and the most common department was emergency ICU (42 persons, 28.8%). The most common job title was registered nurse (137 persons, 97.2%). Second, Participants scored 15.44±2.28 for knowledge about withdrawing life-sustaining treatment, 3.45±0.36 for attitude toward withdrawing life-sustaining treatment, 5.09±0.45 for moral sensitivity, 3.00±0.24 for biomedical ethical awareness, and 3.99±0.43 for role perception of withdrawing life-sustaining treatment. Third, Among general and work-related characteristics, knowledge about withdrawing life-sustaining treatment differed significantly depending on age (F=3.24, p=.024), marital status (t=-2.40, p=.018), and total work experience (F=4.02, p=.004). Fourth, Among general and work-related characteristics, attitudes toward withdrawing life-sustaining treatment differed significantly depending on experience working in the ICU (F=2.79, p=.043). Fifth, Among general and work-related characteristics, moral sensitivity differed significantly depending on total work experience (F=2.52, p=.044). Sixth, Among general and work-related characteristics, biomedical ethical awareness differed significantly depending on total work history (F=2.51, p=.045) and experience working in the ICU (F=2.86, p=.040). Seventh, The role perception of withdrawing life-sustaining treatment did not show any statistically significant differences depending on general and work-related characteristics. Eighth, The correlation of role perception of withdrawing life-sustaining treatment with knowledge and attitudes, moral sensitivity, biomedical ethical awareness, attitude showed a significant positive correlation with role perception (r=.25, p=.003), role perception also showed significant positive correlations with moral sensitivity (r=.38, p<.001) and biomedical ethical awareness (r=.17, p=.050). Ninth, The results of analyzing the factors influencing role perception of withdrawing life-sustaining treatment, attitudes (β=.25, p=.001) and moral sensitivity (β=.36, p<.001) were identified as predictive variables. The variable with the largest effect was moral sensitivity, accounting for 19.8% of the variance in role perception. Conclusion : This study identified attitudes toward withdrawing life-sustaining treatment and moral sensitivity as predictive variables influencing the role perception of withdrawing life-sustaining treatment. Therefore, to improve role perception of withdrawing life-sustaining treatment, diverse efforts will be required, including improving attitudes and moral sensitivity and providing specialized education. 목적 : 본 연구는 중환자실 간호사를 대상으로 연명의료중단에 대한 지식과 태도, 도덕적 민감성, 생명의료 윤리의식이 연명의료중단에 대한 역할인식에 미치는 영향 요인을 파악하여 중환자실 간호사의 연명의료중단에 대한 역할인식 향상에 필요한 기초 자료를 제공하는 데 목적이 있다. 방법 : 본 연구는 중환자실 간호사의 연명의료중단에 대한 지식과 태도, 도덕적 민감성, 생명의료 윤리의식이 연명의료중단에 대한 역할인식에 미치는 영향을 확인하기 위한 서술적 조사연구이다. 자료는 I시 소재 일개 상급종합병원 중환자실에 근무하는 간호사로 연구에 동의하고 설문조사에 임한 간호사를 대상으로 하였다. 자료수집 기간은 2023년 6월 13일부터 2023년 6월 21일까지였고, 150부의 구조화된 설문지를 배부하여 144부를 회수하였고 141부를 최종 분석에 사용하였다. 수집된 자료는 SPSS 26.0 program을 이용하여 빈도와 백분율, 평균과 표준편차, t-test, ANOVA, Pearson’s Correlation coefficient, Multiple regression으로 분석하였다. 결과 : 본 연구의 결과를 요약하면 다음과 같다. 첫째, 대상자의 일반적 및 근무 관련 특성에서 연령은 평균 29.03±6.60세로 26세∼29세가 53명(37.6%)으로 가장 많았으며, 성별은 여자가 115명(81.6%)으로 많았다. 최종 학력은 학사 이상이 116명(82.3%)으로 많았으며, 결혼 상태는 미혼이 114명(80.9%)으로 많았다. 종교는 무교가 86명(61.6%)으로 가장 많았고, 총 근무경력은 1년 이상∼3년 미만이 55명(39.0%)이 가장 많았다. 중환자실 경력 또한 1년 이상∼3년 미만이 63명(44.7%)으로 가장 많았으며, 근무부서는 응급중환자실이 36명(25.5%)으로 가장 많았다. 직위는 일반간호사가 137명(97.2%)으로 가장 많이 나타났다. 둘째, 대상자의 연명의료중단에 대한 지식은 15.44±2.28점이고, 연명의료중단에 대한 태도는 3.45±0.36점이며, 도덕적 민감성은 5.09±0.45점, 생명의료 윤리의식은 3.00±0.24점, 연명의료중단에 대한 역할인식은 3.99±0.43점이었다. 셋째, 대상자의 일반적 및 근무 관련 특성에 따른 연명의료중단에 대한 지식의 차이는 연령(F=3.24, p=.024), 결혼 상태(t=-2.40, p=.018), 총 근무경력(F=4.02, p=.004)에서 유의한 차이가 있었다. 넷째, 대상자의 일반적 및 근무 관련 특성에 따른 연명의료중단에 대한 태도의 차이는 중환자실 경력(F=2.79, p=.043)에서 유의한 차이를 보였다. 다섯째, 대상자의 일반적 및 근무 관련 특성에 따른 도덕적 민감성의 차이는 총 근무경력(F=2.52, p=.044)에서 유의한 차이를 보였다. 여섯째, 대상자의 일반적 및 근무 관련 특성에 따른 생명의료 윤리의식의 차이는 총 근무경력(F=2.51, p=.045), 중환자실 경력(F=2.86, p=.040)에서 유의한 차이를 보였다. 일곱째, 대상자의 일반적 및 근무 관련 특성에 따른 연명의료중단에 대한 역할인식은 통계적으로 유의한 차이를 보이지 않았다. 여덟째, 연명의료중단에 대한 지식과 태도, 도덕적 민감성, 생명의료 윤리의식, 연명의료중단에 대한 역할인식의 상관관계는 연명의료중단에 대한 태도는 연명의료중단에 대한 역할인식(r=.25, p=.003)과 유의한 양의 상관관계가 있었고, 연명의료중단에 대한 역할인식은 도덕적 민감성(r=.38, p<.001), 생명의료 윤리의식(r=.17, p=.050)과 양의 상관관계를 보였다. 아홉째, 연명의료중단에 대한 역할인식에 영향을 미치는 요인을 분석한 결과 예측 변인은 연명의료중단에 대한 태도(β=.25, p=.001)와 도덕적 민감성(β=.36, p<.001)으로 나타났다. 가장 큰 영향을 미치는 변수는 도덕적 민감성이었고 연명의료중단에 대한 역할인식에 미치는 영향에 대한 설명력은 19.8%이었다. 결론: 본 연구 결과 연명의료중단에 대한 역할인식에 영향을 미치는 예측 변인은 연명의료중단에 대한 태도와 도덕적 민감성으로 나타났다. 따라서 연명의료중단에 대한 역할인식을 높이기 위해서는 연명의료중단에 대한 태도와 도덕적 민감성 향상과 특성화된 교육 제공 등의 다양한 노력이 필요하다.

(The) effect of the life-sustaining treatment plan on healthcare expenditure and healthcare utilization among cancer patients

김세린 Graduate School, Yonsei University 2021 국내석사

서론: 암환자의 의료비는 진단 전 급격히 증가했다가 진단 후 감소했다가 죽음에 가까워 지면서 다시 급증하는 양상을 보인다. 의료이용 역시 사망 마지막 한 달 동안 증가한다. 이에 무의미한 연명의료를 거부할 수 있는 환자의 권리가 논의됐고, 연명의료중단에 관한 법률이 제정되었다. 말기 환자와 임종 직전의 환자는 자신의 연명의료 중단에 관하여 연명의료계획서를 작성할 수 있다. 이 연구는 암으로 사망한 환자의 연명의료계획서 작성이 의료비 지출 및 의료이용에 미치는 영향을 분석하고자 하였다. 연구방법: 이 연구는 2018년부터 2020년까지 수집된 국민건강보험공단 청구 자료를 사용하였다. 암환자 중 연명의료계획서 작성군과 비작성군을1:1 성향점수매칭기법을 사용하여 총 23,494명의 대상자를 산출해냈다. 작성군과 비작성군의 사망 전 의료비와 의료이용을 사망 전 30일, 60일, 90일의 3구간으로 나누어 분석하였다. 연명의료계획서 작성 여부가 의료비와 의료이용에 미치는 영향을 알아보기 위하여 일반화선형모델을 사용하였다. 암종과 따라 하위그룹분석을 실시하였다. 연구결과: 대상자 23,494명 중 작성군과 비작성군은 각각 11,747명이었다. 30일 이상 생존한 그룹이 11,301명, 60일 이상 생존한 그룹이 5,173명, 90일 이상 생존한 그룹이 3,005명이었다. 비작성군에 비해 작성군의 총의료비는 사망 30일 (EXP(ß): 0.81, 95% CI: 0.78-0.85), 60일 (EXP(ß): 0.90, 95% CI: 0.90-0.99)에서 적었다. 4가지 연명의료에서 중 CPR과 항암치료가 비작성군에 비해 작성군의 의료비가 적었다. 그러나 호스피스 비용과 이용은 비작성군에 비해 작성군에서 더 높은 EXP(ß)을 보였다. 결론: 이 연구에서는 연명의료계획서 작성이 사망 전 30일 동안 의료비와 의료이용을 감소 시킨다는 분석결과를 확인하였다. 그러나 호스피스의 이용 및 비용이 증가한 것으로 분석되었다. 연명의료계획서 작성이 의료비와 의료이용을 줄일 수 있기 때문에 연명의료계획서 작성을 위해 의료진, 환자 및 보호자를 교육하고 홍보할 필요가 있다. Background: The medical costs of cancer treatment increase rapidly before diagnosis, decrease after diagnosis, following which they increase again rapidly, towards the end of life. Healthcare utilization also increases in the last months of life. The rights of patients to refuse life-sustaining treatment have been discussed, and the law to opt for our life-sustaining treatment have also been established. Terminally ill patients at the final stage of life choose to have in writing their Life-sustaining Treatment Plan (LSTP) to determine their end-of-life care process. This study investigated the effects of the Life-sustaining Treatment Plan on healthcare expenditure and utilization among patients who died from cancer. Methods: The data for this study were obtained from the National Health Information DB, collected by the National Health Insurance Service of Korea, between 2018 and 2020. We included 23,494 participants who died from cancer after their propensity score matched a 1:1 ratio. Between the LSTP and control groups, healthcare expenditure and utilization were analyzed for the following three spans of time: 30 days, 60 days, and 90 days before death. The effect of LSTP on healthcare expenditure and utilization was examined by a regression analysis with a generalized linear model. Subgroup analyses were conducted according to the cancer type. Results: Among the 23,494 participants, 11,747 were in the LSTP group and 11,747 were in the control group. 11,301 (LSTP group: 5,740, control: 5,561), 5,173 (LSTP group: 2,680, control: 2,493), 3,005 (LSTP group: 1,567, control: 1,438) were alive for more than 30 days, 60 days, and 90 days, respectively. Compared to the control group, the LSTP group had a lower EXP(ß) of 0.81 and 0.94 of total cost in the last 30 days of life (95% CI: 0.78-0.85) and in the last 60 days of life (95% CI: 0.90-0.99). Among the four life-sustaining treatments, CPR and chemotherapy cost and utilization were lower in the LSTP group than in the control group. However, the LSTP group had a higher EXP(ß) of hospice cost and use in the last 30, 60, and 90 days of life. Conclusions: This study found that the LSTP reduced healthcare expenditure and utilization in the last 30 days of life. However, we found an increase in the cost and use of hospice. As LSTP can reduce some healthcare expenditures and utilization, it is necessary to educate and promote the medical staff, patients, and their caregivers to prepare relevant LSTPs.

환자들의 연명치료에 대한 이해도가 사전의료의향서 작성의지에 미치는 영향

최진경 경북대학교 대학원 2013 국내석사

Effects of Patient’s Understanding of Life-Sustaining Treatment on the Will to Complete Advanced Directives Jin Kyung Choi Department of Nursing Graduate School, Kyungpook National University Dsegu, Korea (Supervised by Professor Kim, Su-Hyun) (Abstract) This study aimed to identify the effects of patients’ understanding of life-sustaining treatment on the will to complete advanced directives in middle-aged and elderly patients. The study collected data by conducting a survey with structured questionnaires to over-40-year old 187 out-patients in two general hospitals in North Gyeonsang Province from September 26 to October 9, 2012. Collected data were analyzed using hierarchical logistic regression. The average point in the understanding of life-sustaining treatment was 6.85(±2.32) with a perfect score of 13 points. The understanding on CPR complications and resuscitation rate, in particular, were found to be only 37% and 8.6%, respectively. In terms of life-sustaining treatment, 65.3% respondents answered that hospitals need to refrain from practicing unnecessary CPR on patients who do not need. Although most respondents agreed on advanced directives, only 57% respondents were determined to complete advanced directives. The understanding on life-sustaining treatment significantly increased the will to complete advanced directives when patients were controlled with age, health condition, the witness of CPR or artificial respirator use, family functioning, and attitude toward life-sustaining treatment(OR=1.27, 95%CI 1.09-1.48). Moreover, the attitude toward life-sustaining treatment was shown to be significantly influenced in writing advanced directives (OR=2.47 95%CI 1.21-5.03). The study verified that the understanding of life-sustaining treatment increased patient’s will to write advanced directives. Therefore, healthcare providers need to enhance patients’ understanding of life-sustaining treatment by providing accurate information on life-sustaining treatment including clinical CPR. Furthermore, proactive publicity and proper education to healthcare providers, as well as, ordinary people are thought to be crucial to encourage writing advanced directives preserving respect for patient autonomy.

연명의료결정의 법률적 쟁점 및 향후과제에 관한 비교법적 고찰

정유진 연세대학교 대학원 2017 국내석사

암환자의 사전연명의료의향서 지식과 좋은 죽음 인식이 연명의료중단 태도에 미치는 영향

박상언 경상대학교 대학원 2020 국내석사

본 연구는 암환자의 사전연명의료의향서 지식, 좋은 죽음 인식이 연명의료중단 태도에 영향을 파악하여 암환자의 연명의료중단 결정에 대한 자기결정 활성화를 위한 간호 중재프로그램 개발의 기초 자료를 제공하고자 시도된 서술적 조사연구이다. 연구의 대상자는 G도의 J시 G대학병원에서 외래 또는 입원치료를 받고 있는 20세 이상의 성인 암환자로 2019년 9월 15일부터 2020년 3월 30일까지 실시하였고, 자료수집은 자가보고식 설문지를 이용하여 총 167부의 설문지가 최종 분석되었다. 본 연구의 주요결과는 다음과 같다. 1) 성별은 남자 85명(50.9%), 평균 연령은 58.74세였다. 결혼 여부는 기혼이 124명(74.3%), 종교는 있음이 107명(64.1%), 교육 정도는 고졸이 69명(41.3%), 암 진단은 혈액암이 50명(29.9%)이었고, 건강상태는 ‘보통’이라고 응답한 대상자가 80명(47.9%), 연명의료중단 논의 여부는 ‘아니오’라고 대답한 대상자가 127명(76.0%), 가족이나 친척, 가까운 지인의 연명의료중단 경험에 대한 항목에서 ‘아니오’라고 응답한 대상자가 141명(84.4%), 사전의료의향서 작성 시기에 대해 ‘중병에 걸렸을 때’ 항목을 선택한 대상자가 60명(38.9%) 이었다. 2) 대상자의 사전연명의료의향서 지식의 평균 평점은 0.74±0.21점 이었다. 좋은 죽음 인식의 평균 평점은 2.87±0.42점이었다. 하부영역을 살펴보면 친밀감의 평균 평점은 2.90±0.43점이었고, 통제감의 평균 평점은 2.79±0.65점이었으며, 임상증상의 평균 평점은 2.86±0.54점으로 나타났다. 연명의료중단 태도의 평균 평점은 3.46±0.49점이었다. 3)연명의료중단 태도에 영향을 미치는 요인을 다중회귀분석방법으로 분석한 결과, 연명의료중단에 미치는 영향요인으로는 가족과 연명의료중단 논의 여부, 사전연명의료의향서 지식, 좋은 죽음 인식으로 나타났으며 설명력은 16.0%이었다(F=10.355, p<.001). The purpose of this study is to identify the factors the affecting Attitude toward withdrawal of life-sustaining treatment of cancer patients and to provide the elementary data for the development of nursing intervention programs for cancer patient‘s self-determination regarding its decision to withdrawal life-sustaining treatment. The data were collected form September 15. 2019 to March 30. 2020 by using structured questionnaires for 167 patients who visited in G National University of Hospital in Gyeongnam, Republic of Korea. To evaluate the Knowledge of Advanced Directives, the tool was used which was developed by Hong & Kim (2013) and amended & supplemented by Seo(2019); with regard to the Perception of Good death the tool developed by Schwartz et al.(2003); in order to Attitude toward Withdrawal of Life-Sustaining Treatment was measured by a diagnostic tool developed by Park (2000), revised by Byun (2003) and 2 questions were removed because that could put a psychological burden on Cancer Patients. The collected data were analyzed using SPSS/WIN 21.0 program. specifically, using independent t-test, one-way ANOVA, Scheffé test, Pearson’s correlation coefficient, and multiple regression. The results of this study are as follows. 1) The average score of Knowledge of Advanced Directives for cancer patients is 0.74±0.21(range 0-1) and that of Perception of Good Death is 2.87±0.42(range 1-4). of the Attitude toward Withdrawal of Life-Sustaining Treatment is 3.46±0.49(range 1-5). 2) The subjects’ Attitude toward Withdrawal of Life-Sustaining Treatment is significantly different depending on Whether to discuss Withdrawal of Life-Sustaining Treatment(t=3.232, p=.001). 3) The Attitude toward Withdrawal of Life-Sustaining Treatment is positively correlated with Knowledge of Advanced Directives(r=.196, p=.011), Perception of Good Death(r=.305, p<.001). 4) The most influencing factor of Attitude toward Withdrawal of Life-Sustaining Treatment among cancer patients is Perception of Good Death(β=.273, p<001), Whether to discuss Withdrawal of Life-Sustaining Treatment(β=.195, p=.008), Knowledge of Advanced Directives(β=.148, p=.043). The relevant variables have 16.0% influence(F=10.355, p<.001) on the rehabilitation adherence of the stroke patients. In conclusion, these results suggest that Knowledge of Advanced Directives, Perception of Good Death have an important on Attitude toward Withdrawal of Life-Sustaining Treatment. Therefore, nursing interventions to increase Knowledge of Advanced Directives and Perception of Good Death should be developed for Cancer patients.

연명치료 중단과 사전의사결정에 관한 고찰

이금미 연세대학교 보건대학원 2007 국내석사

말기환자의 연명치료 중단은 임상에서 종종 시행되고 있으나, 이에 대한 법체계는 물론이고, 사회적 합의도 되어있지 않은 상황이다. 따라서, 이 연구는 말기환자의 연명치료 중단에 대한 일반인의 태도를 확인하고, 사회적 합의를 얻어, 사전의사 결정서의 필요성을 제시하고자 시도하였다.본 연구는 2006년 8월과 9월에 의무기록을 중심으로 사례를 수집하였으며, 사례별 연명치료 중단에 대한 일반인의 태도는 서울시 Y대학병원의 환자를 제외한 보호자나 방문객 38명, 병원외 일반인 83명으로 본 연구 참여에 동의한 사람만을 상대로 2006년 10월에 구조화된 설문지를 통해 이루어졌다. 수집된 자료는 부호화하고 SPSS 12.0 for Window program을 이용하여 기술통계, chi-square test로 분석하였다.본 연구의 결과는 다음과 같다.1.사례별 연명치료 중단에 대한 태도에서 환자 의식이 있으면서, 본인이 연명치료 중단을 원하는 사례1의 경우 중단 할 수 있다는 응답이 94명(79%)이었고,의식이 혼미하고 치매인 회복 불가능한 고령의 환자인 사례2는 전체 응답자의 71명(59.7%)가 연면치료 중단을 할 수 있다고 하였으며, 사례3의 경우는 전체 72명(60.5%)가 연명치료 중단을 할 수 있다고 답하여 비교적으로 사례1에서 연명치료를 중단할 수 있다는 비율이 높았다(표4). 그러나, 세 개의 사례 모두 일반적 특성에 따른 유의한 차이는 없었다.2. 사례별 연명치료 중단 결정의 이유는 ‘환자의 고통을 덜어주어 존엄한 죽음을 맞도록 한다.‘라고 답한 사람이 사례1,2,3 각각 81명(86%), 47명(66%), 42명(58%)로 다른 이유보다 가장 빈도가 높았다.3. 연명치료 여부에 관한 결정권자는 환자가 의식이 있을 때는(사례1) 환자가 결정해야 한다고 답한 경우가 76명(63%)이었고, 환자가 결정을 내릴 수 없는 경우(사례2, 사례3)는 가족과 주치의가 결정해야 한다는 대답이 55명(46.2%), 56명(47.1%)으로 가장 높게 나타났으며, 일반적 특성에 따른 유의한 차이는 없었다.4. 사전의사 결정서가 필요하냐는 질문에 대상자의 98명(82.4%)이 ‘필요하다.’라고 했으며, 20대와 30대에서 ‘필요하지 않다.’라는 응답이 5%, 9.2%에 비해 40대이상에서는 14.3%로 다소 높았으며, 성별로는 남녀 불문하고 80%이상에서 사전의사 결정서가 ‘필요하다’ 라고 답하였다. 말기환자 간호경험에서 직접간호한 사람의 25명(92.6%)이 전혀 경험하지 않은 52명(78.8%)보다 높게 나타났다. 그러나 일반적 특성에 따른 사전의사 결정서의 필요성에 대한 유의한 차이는 없었다.5. 자기 자신에게 사전의사 결정서를 작성할 것인지를 묻는 질문에 81명(68.1%)이 ‘예’라고 하였고, ‘잘 모르겠다.’라고 한 사람도 25명(21%)이었다. 사전의사 결정서 작성시기로는 전체의 62명(52.1%)이 말기병 진단시 작성하겠다고 응답하였고 24명(20.2%)은 임박한 죽음의 증상시에 작성하겠다고 응답하였다.6. 병원 윤리위원회가 필요하다고 생각하냐는 질문에 전체의 72명(61%)이 필요하다고 하였고, 나머지 47명(39%)은 필요하지 않다라고 응답하였다. 다른 일반적 특성에 따른 병원 윤리위원회의 빈도차는 크지 않았다.7. 병원 윤리위원회의 법적 효력에 대해서는 47명(65%)가 법적 효력이 있어야 한다고 하였다. 또한, 치료중단의 결정권자와 절차에 대한 정당한 법적 장치 마련시 치료 중단을 행할 것이냐는 질문에 87명(73%)이 필요하다고 나타났다. 말기환자 간호경험에서는 직접간호한 사람의 85.2%에서 필요하다고 응답하였다.결론적으로 일반인은 환자의 자기결정권을 존중하고 있었으며, 사전의사 결정서와 병원 윤리위원회의 필요성을 인식하고, 연명치료 중단에 대한 법적 장치에 대해서도 필요성을 나타내었다. 따라서 환자의 의식이 있을때 연명치료에 대한 본인의 의사를 담은 사전의사 결정서를 제도화하고 미처 준비가 되지 않았을 경우 병원 윤리위원회의 자문을 얻는 절차적인 제도가 마련되어야 할 것이다. Even though the withdrawal of life-sustaining treatment on patients in the terminal stage is often being exercised clinically, we have not set up a social agreement as well as the legal basis for this matter yet. Therefore, this study aims at suggesting the requirement of the advanced directive form for the suspension of life expending therapy by checking out the people's attitudes to this practice, and winning the social agreement.The cases in the study were collected based upon the medical records in August and September, 2006. With regard to the people's attitudes to the case-by-case suspension of life expending therapy, the survey wasdone through the patterned questionnaire among 38 of protectors or visitors except for the patients of Y university hospital, and another 83 people besides hospital, who agreed upon participating in the study in October, 2006. The data collected was coded, and analyzed in the manner of chi-square test of descriptive statistics with the use of SPSS 12.0 for Window program.The result of the study is as follows.1. As for the people's attitudes to the case-by-case withdrawal of life-sustaining treatment, in case 1 that the patient is conscious, and wants the withdrawal of life-sustaining treatment, 94(79%)of respondents answered positively 'Can withdrawal of life-sustaining treatment', and in case 2 of the aged patient diagnosed as senile dementia whose consciousness is in confusion, 71(59.7%) among the total respondents gave positive answer. In case 3, 72(60.5%) of respondents replied positively; the case 1 showed relatively high ratio of 'can withdrawal of life-sustaining treatment'(Table 4). But in all cases of three, the attentive differences by generally characteristic were not found out.2. Regarding the reason for the withdrawal of life-sustaining treatment, 'To help patients to face the dignitary death by relieving them from pains' was the most frequent answer compared to other reasons; it was selected by 81(86%) of respondents in case 1, 47(66%) in case 2, and 42(58%) respectively.3. Regarding the decision-maker on whether to practice life-sustaining treatment , in case 1 that the patient is conscious, 76(63%) of respondents answered 'Patient should decide', and in case 2, 3 that the patient is not able to decide, 'Family members or doctors in charge are responsible for decision', was answered by 55(46.2%), 56(47.1%) of respondents each showing the highest frequency. The attentive differences by general characteristic were not found out.4. For the question on the requirement for writing a advanced directive, 98(82.4%) of respondents answered 'Required', and 'Not required' was relatively a bit higher as 14.3% in the answers of over 40s than in 20s and 30s whose ratio shower 5%, and 9.2% each. Also 'Required' was over 80% in both sexes, and 25(92.6%) among the respondents who experienced nursing the patients in terminal stage, higher than 52(78.8%) from the respondents who had no experience of nursing. But the attentive differences about the requirement for writing a advanced directive by general characteristic were not found out.5. About the question asking whether to write advanced directive, 81(68.1%) of respondents answered 'YES', and 25(21%) of respondents responded as 'DO NOT KNOW'. With regard to the timing of writing advanced directive, 62(52.1%) among the total respondents answered 'When diagnosed as being critically ill', and 24(20.2%) answered 'At the symptom of impending death'.In conclusion, people respect the right of self-decision of patients, recognizing the requirement for writing a advanced directive, organizing ethics committee in hospital, and legal device for the suspension of life expending therapy. Accordingly, writing advanced directive, which contains the patients' opinion on the life extending therapy while they are conscious, should be institutionalized, and also the procedures, which enable the patients to get help through the advice of ethics committee in hospital should even in case that it is not prepared in time, should be institutionalized.