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.

중환자실 간호사의 연명의료 중단에 대한 태도, 연명의료 간호 스트레스, 도덕적 고뇌가 소진에 미치는 영향

양지연 부산대학교 대학원 2024 국내석사

연구목적: 본 연구의 목적은 중환자실 간호사의 연명의료 중단에 대한 태도, 연명의료 간호 스트레스, 도덕적 고뇌 및 소진의 정도와 소진에 영향을 미치는 요인을 확인하기 위함이다. 연구방법: 본 연구는 서술적 조사연구로, 대상자는 중환자실에 근무하면서 연명의료 간호를 직접 제공하는 간호사 162명이다. 자료는 2024년 1월 15일부터 2024년 2월 28일까지 온라인 설문조사로 수집하였다. 연구도구는 자가보고형 조사지로, 일반적 특성 및 직무관련 특성, 연명의료 중단에 대한 태도, 연명의료 간호 스트레스, 도덕적 고뇌와 소진으로 구성되었다. 소진은 정서적 고갈, 자아성취감 저하, 비인간화로 구성되어 있다. 수집된 자료는 SPSS Statistics 27.0 program을 이용하여 기술통계, Independent t-test, one-way ANOVA, Pearson’s correlation coefficient, Hierarchical regression으로 분석하였다. 연구결과: 대상자의 연명의료 중단에 대한 태도는 평균 평점 5점 만점에 3.53±0.41점, 연명의료 간호 스트레스는 평균 평점 5점 만점에 3.07±0.38점, 도덕적 고뇌는 336점 만점에 92.27±58.52점이었다. 대상자의 정서적 고갈은 54점 만점에 30.90±9.86점, 자아성취감 저하는 48점 만점에 18.20±8.28점, 비인간화는 30점 만점에 13.38±5.92점이었다. 대상자의 정서적 고갈에 영향을 미치는 요인은 직업선택동기가 적성 및 흥미(β=-.29, p<.001)와 연명의료 간호 스트레스(β=.30, p<.001)였고 회귀모형의 설명력은 17.0%이었다(F=5.21, p<.001). 대상자의 자아성취감 저하에 영향을 미치는 요인은 중환자실 경력(β=-.26, p=.018)과 연명의료 간호 스트레스(β=.20, p=.021)였고 회귀모형의 설명력은 9.0%이었다(F=3.78, p=.003). 대상자의 비인간화에 영향을 미치는 요인은 도덕적 고뇌(β=.24, p=.003)와 연명의료 중단에 대한 태도(β=.16, p=.045)였고 회귀모형의 설명력은 19.0%이었다(F=4.76, p<.001). 결론: 중환자실 간호사의 정서적 고갈을 감소시키고, 자아성취감을 높이기 위해 스트레스 관리 프로그램의 개발 및 적용이 필요하다. 중환자실 간호사의 비인간화를 감소시키기 위해서 도덕적 고뇌의 상황적 제약이나 조직적 제약을 최소화하고, 연명의료 중단에 대한 혼란 없이 결정을 내릴 수 있도록 명확한 병원 내 지침과 절차를 마련할 필요가 있다. 또한 연명의료 결정에 관한 다양한 사례 기반 교육으로 연명의료 결정제도에 대한 지식을 갖추고, 연명의료 중단 상황에서 간호사가 어떤 결정을 내려야 하는지를 훈련할 수 있도록 지원해야 할 것이다. Objective: This study aimed to attitude toward withdrawal of life-sustaining treatment, life-sustaining treatment nursing care stress, moral distress, and degree of burnout syndrome among intensive care unit nurses and identify factors associated with burnout syndrome. Methods: Through an online survey conducted from January 15, 2024, to February 28, 2024, data were collected from 162 nurses who directly provided life-sustaining medical care and worked in the intensive care unit among members of the Hospital Critical Care Nursing Association. The survey comprised a self-reported questionnaire that contained measurement tools for general and job-related characteristics, attitude toward withdrawal of life-sustaining treatment, life-sustaining treatment nursing care stress, moral distress, and burnout syndrome. Burnout syndrome consists of emotional exhaustion, personal accomplishment, and depersonalization. Descriptive statistics, independent t-test, ANOVA, Pearson’s correlation coefficient, and hierarchical regression analysis were performed using SPSS 27.0. Result: The mean attitude toward withdrawal of life-sustaining treatment was 3.53±0.41 points out of 5, life-sustaining treatment nursing care stress was 3.07±0.38 out of 5, and moral distress was 92.27±58.52 out of 336. The mean emotional exhaustion was 30.90±9.86 points out of 54, the mean personal accomplishment score was 18.20±8.28 out of 48, and the mean depersonalization score was 13.38±5.92 out of 30. Aptitude and interest (β=-.29, p<.001) and Life-sustaining treatment nursing care stress (β=.30, p<.001) appeared in order as factors of emotional exhaustion. In addition, the explanatory power of the model was 17% (F=5.21, p<.001). Intensive care unit experience (β=-.26, p=.018) and Life-Sustaining treatment nursing care stress (β=.20, p=.021) appeared in order as factors of personal accomplishment. In addition, the explanatory power of the model was 9% (F=3.78, p=.003). Moral distress (β=.24, p=.003) and attitude toward withdrawal of life-sustaining treatment (β=.16, p=.045) appeared in order as factors of depersonalization. In addition, the explanatory power of the model was 19% (F=4.76, p<.001). Conclusion: Stress management programs should be developed and implemented to reduce emotional exhaustion among intensive care unit nurses and increase their personal accomplishment. In order to reduce the depersonalization of intensive care unit nurses, life-sustaining treatment guidelines should be established to minimize situational or organizational constraints on moral distress. In addition, It is possible to have knowledge of the life-sustaining treatment decision system through various case-based education on life-sustaining treatment decisions and to respect the opinions and decisions of patients and guardians on the withdrawal of life-sustaining treatment.

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.

일 종합병원 간호사의 연명의료에 대한 지식, 태도, 역할인식과 간호 스트레스

안현빈 연세대학교 대학원 2024 국내석사

This study aims to identify the relationship between knowledge, attitudes, role perception, and the degree of nursing stress related to life-sustaining treatment among nurses working at a general hospital, and to clarify the factors related to nursing stress related to life-sustaining treatment. The study also seeks to provide basic data for interventions to alleviate this stress. This descriptive survey research was conducted through a self-report questionnaire administered to 121 nurses at a tertiary general hospital in K Province. The research tools used include the knowledge measurement tool for life-sustaining treatment developed by Hong Suyeon et al. (2020), the attitude tool towards life-sustaining treatment based on the tool by Park Gyeseon (2020) and modified by Byeon Eunkyung et al. (2003), the role perception tool for life-sustaining treatment developed by Byeon Eunkyung et al. (2003), and the nursing stress tool related to life-sustaining treatment developed by Lee Sujeong et al. (2017). The collected data were analyzed using SPSS/WIN 29.0 with descriptive statistics, Independent t-test, One way ANOVA, post hoc analysis Scheffé test, Pearson’s correlation coefficient, and Multiple linear regression. The main results of this study are as follows. 1. The average knowledge score regarding life-sustaining treatment was 13.69 (±2.48), with an average rating of 0.60 (±1.11). The average attitude score was 61.80 (±7.46), with an average rating of 3.64 (±0.44). The average score for role perception regarding life-sustaining treatment was 49.78 (±6.25), with an average rating of 3.83 (±0.48). The average nursing stress score related to life-sustaining treatment was 104.72 (±15.26), with an average rating of 3.74 (±0.55). 2. Differences in knowledge regarding life-sustaining treatment based on general characteristics showed statistically significant differences by gender (t=-2.06, p=.042), age (F=6.36, p=.002), marital status (t=-2.47, p=.015), religion (t=2.06, p=.041), work experience (F=3.19, p=.045), and experience in life-sustaining treatment education (F=2.24, p=.027). Knowledge was higher in those aged 40 and over (15.53±3.42), married (14.50±2.81), with a religion (14.36±2.82), with over 7 years of work experience (14.45±2.75), and those with experience in life-sustaining treatment education (14.40±2.63). There were no statistically significant differences in attitudes, role perception, and nursing stress related to life-sustaining treatment based on general characteristics. 3. Nursing stress related to life-sustaining treatment had a significant positive correlation with role perception (r=.33, p<.001), while knowledge and attitudes had no significant correlation with nursing stress. 4. The factor related to nursing stress in life-sustaining treatment was role perception regarding life-sustaining treatment (β=.34, p<.001), and the explanatory power of the model was 10.0%. Based on these results, it was confirmed that the more actively nurses recognize their roles in caring for patients receiving life-sustaining treatment, the more they perceive nursing stress. These findings suggest the need to eliminate factors that hinder nursing performance related to the acceptance and recognition of active roles by nurses, and to seek strategies to support role performance. Particularly, the ambiguity of the scope of nurses' roles and the lack of guidelines for tasks such as communication in life-sustaining treatment may contribute to nursing stress during the performance of life-sustaining treatment nursing. Therefore, it is necessary to clearly define and document the scope of nurses' roles, including authority and responsibility, in guidelines for life-sustaining treatment nursing. To this end, it is necessary to develop and implement educational programs on life. 본 연구는 일 종합병원에 근무하는 간호사를 대상으로 연명의료에 대한 지식, 태도, 역할인식과 연명의료 간호 스트레스의 정도 관계를 파악하고, 연명의료 간호 스트레스 관련 요인을 규명하여 연명의료 간호 스트레스 중재를 위한 기초자료를 제공하기 위하여 시도되었다. 본 연구는 서술적 조사연구로 K도 소재 일 상급종합병원의 간호사 121명을 대상으로 자가보고 방식의 설문 조사로 시행되었다. 연구 도구는 홍수연 등(2020)이 개발한 연명의료 지식 측정 도구, 박계선(2020)의 도구를 기초하여 변은경 등(2003)이 수정 및 보완한 연명의료 태도 도구, 변은경 등(2003)이 개발한 연명의료 역할인식 도구, 이수정 등(2017)이 개발한 연명의료 간호 스트레스 도구를 사용하였다. 수집된 자료는 SPSS/WIN 29.0을 이용하여 기술통계, Independent t-test, One way ANOVA, 사후분석 Scheffé test, Pearson’s correlation coefficient, Multiple linear regression을 이용하여 분석하였다. 본 연구의 주요 결과는 다음과 같다. 1. 대상자의 연명의료에 대한 지식의 평균은 13.69점(±2.48), 평균 평점은 0.60점(±1.11)이었고, 연명의료에 대한 태도의 평균은 61.80점(±7.46), 평균 평점은 3.64점(±0.44)이었다. 연명의료에 대한 역할인식의 평균은 49.78점(±6.25), 평균 평점은 3.83점(±0.48)이었고, 연명의료 간호 스트레스의 평균은 104.72점(±15.26), 평균 평점은 3.74점(±0.55)이었다. 2. 일반적 특성에 따른 연명의료에 대한 지식의 차이에서는 성별(t=-2.06, p=.042), 연령(F=6.36, p=.002), 결혼상태(t=-2.47, p=.015), 종교(t=2.06, p=.041), 근무경력(F=3.19, p=.045), 연명의료 교육경험(F=2.24, p=.027)에서 통계적으로 유의한 차이가 있었으며, 지식은 40대 이상(15.53±3.42)인 경우, 기혼(14.50±2.81)인 경우, 종교가 있는(14.36±2.82) 경우, 근무경력이 7년 이상(14.45±2.75)이, 연명의료 교육경험이 있는(14.40±2.63) 경우에 높았다. 일반적 특성에 따른 연명의료에 대한 태도, 역할인식, 간호 스트레스는 통계적으로 유의한 차이가 없었다. 3. 연명의료에 대한 간호 스트레스는 역할인식(r=.33, p<.001)과 유의한 양의 상관관계가 있었으며, 반면 연명의료에 대한 지식과 태도는 유의한 상관관계가 없었다. 4. 연명의료 간호 스트레스 관련이 있는 요인은 연명의료에 대한 역할인식((β=.34, p<.001)이었으며 모형의 설명력은 10.0%이었다. 이상의 연구결과를 통해 본 연구대상 간호사들이 연명의료 환자를 간호함에 있어서 간호사의 연명의료에 대한 역할을 적극적으로 인식할수록 오히려 간호 스트레스를 더 많이 인식하고 있음이 확인되었다. 이러한 연구결과를 바탕으로 간호사가 적극적인 역할을 수용 및 인식에 따르는 간호 수행에 저해되는 요소 제거와 역할수행을 지지하기 위한 전략 모색이 필요하다. 특히 연명의료에 있어서 간호사의 역할 범위의 불분명과 의사소통 등 업무지침의 부재는 연명의료 간호 수행 시 간호 스트레스에 기여할 소지가 있다고 사료된다. 따라서 연명의료 환자 간호 시 간호사의 역할 범위 즉 권한과 책임 범위를 명확히 지침으로 명문화하는 것이 필요하며, 이를 위해 연명의료 간호에 대한 역할 개발과 아울러 환자 가족, 의료진과의 의사소통을 포함한 연명의료 간호에 대한 교육프로그램을 개발 및 적용하는 것이 필요하다.

장년 남녀의 사전연명의료의향서 작성 의향 관련 요인

김서언 연세대학교 보건대학원 2024 국내석사

배경 및 목적 연명의료결정제도 시행 이후, 사회 전반적으로 환자의 자기결정권에 대한 요구가 높아지는 것으로 파악된다. 하지만 여전히 연명의료결정제도에 대한 인식과 사전연명의료의향서 작성률은 낮은 편이다. 특히 장년(長年)층은 부모나 지인의 사별을 겪게 되면서 죽음에 대한 불안이 가장 높은 시기이며 죽음에 대한 가치관이 변화하는 시기이다. 따라서, 장년층의 사전연명의료의향서 작성 의향을 높이는 것은 이들에게 자신의 죽음을 준비하게 하여 죽음 불안을 감소시키고, 삶의 질을 높이는 것에 도움이 된다. 이에, 본 연구에서는 건강한 장년(만 50세~만 64세) 남녀 206명을 대상으로 사전연명의료의향서 작성 의향 관련 요인을 분석하고자 한다. 연구방법 본 연구는 연세대학교 보건대학원에서 2023년 4월부터 5월까지 만 50세 이상 성인 240명을 대상으로 시행된 온라인 패널조사‘한국 성인의 생애 말기 치료 목표와 가치의 우선순위 및 연명의료 결정 관련 요인' 연구 자료를 활용하였으며, 연구목적에 적합한 만 50세에서 만 64세의 성인 남녀 206명을 대상으로 2차 분석하였다. 연구참여자의 사회경제적 특성, 건강 관련 특성, 연명의료 인지, 사전연명의료 인지, 사별 및 연명의료 경험을 파악하고, 사전연명의료의향서 작성 의향 관련 요인을 파악하기 위하여 다중 로지스틱 회귀분석(Multiple Logistic regression analysis)을 시행하였다. 연구결과 연구참여자는 전체 206명 중 남성 100명, 여성 106명이었으며, 연령대는 50~54세가 49.5%, 거주 지역은 서울 및 수도권이 50.0%, 교육 수준은 대졸 이상이 77.7%, 주관적 건강상태는 '보통'이 62.6%로 가장 많았다. 연명의료에 대한 인지가 있는 사람은 82.0%, 사전연명의료의향서에 대한 인지가 있는 사람은 52.9%였으며, 사별 경험이 있는 사람은 56.3%이었다. 전체 연구참여자 중 83.0%는 사전연명의료의향서 작성 의향이 있었고, 17.0%는 작성 의향이 없었다. 로지스틱 회귀분석 결과, 사전연명의료의향서에 대한 인지가 있는 군에서 그렇지 않은 군에 비하여 사전연명의료의향서 작성 의향 오즈비가 4.32배(OR 4.32, 95% CI 1.59-11.70) 높았으며, 그 외 다른 변수들은 통계적으로 유의한 결과를 보이지 않았다. 결론 지역사회 거주 장년(만 50세~만 64세)의 사전연명의료의향서 작성 의향 관련 요인을 분석한 결과, 사회경제적 특성, 건강 관련 특성, 연명의료 인지, 사별 경험은 사전연명의료의향서 작성 의향과 관련성이 없었으며, 사전연명의료의향서를 인지하고 있어야 사전연명의료의향서 작성 의향이 높아지는 것으로 나타났다. 사전연명의료의향서는 고령화 사회에서 연명의료에 대한 사회적 비용을 절감하고 환자와 환자 가족 간의 의사소통 갈등을 줄이며, 품위 있는 죽음에 필수적인 요소이다. 따라서, 사전연명의료의향서에 대한 인지와 작성률을 높여, 하나의 문화로 정착시키기 위해서는 사전연명의료의향서의 용어와 내용에 대한 대국민 홍보와 교육을 확대해야 할 것이다. Background and Purpose 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, there has been an increase in the demand for patient autonomy across society. However, the awareness of the life-sustaining treatment decision-making system and the completion rate of Advance Directives(ADs) for life-sustaining treatment remain low. Particularly during middle age-a period when individuals often experience heightened anxiety about death, frequently triggered by the death of a parent or acquaintance-values regarding death may change. Therefore, increasing the intention to complete ADs for life-sustaining treatment among middle-aged adults can help them prepare for their own death, reduce death anxiety, and improve their quality of life. Therefore, increasing the intention to complete ADs for life-sustaining treatment among middle-aged adults can help them prepare for their own death, reduce death anxiety, and improve their quality of life. Accordingly, this study aims to analyze the factors related to the intention to complete ADs for life-sustaining treatment among 206 healthy middle-aged men and women aged 50 to 64. Methods This study utilized data from a self-reported online panel survey titled "Priorities in End-of-Life Care Goals and Values and Factors Related to Life-Sustaining Treatment Decisions among Korean Adults" conducted by the Graduate School of Public Health at Yonsei University from April to May 2023. It involved a secondary analysis of 206 adults, both male and female, aged between 50 and 64 years, who fit the research objectives. The research aimed to identify factors related to the intention to complete ADs for life-sustaining treatment. To achieve this, a multiple logistic regression analysis was conducted, adjusting for variables such as the participants' socioeconomic and health-related characteristics. The analysis also incorporated their awareness of life-sustaining treatments, understanding of ADs, and experiences with bereavement and life-sustaining treatment decisions. Results Among the 206 participants, there were 100 men and 106 women. The age distribution showed that 49.5% were between 50 and 54 years old, 50.0% resided in Seoul and the metropolitan area, 77.7% had a college education or higher, and 62.6% reported their health as 'average'. Awareness of life-sustaining treatment was present in 82.0% of participants, while awareness of ADs for life-sustaining treatment was 52.9%. Furthermore, 56.3% had experienced bereavement. Among all participants, 83.0% expressed an intention to complete ADs for life-sustaining treatment, whereas 17.0% did not intend to complete one. The logistic regression analysis revealed that participants who were aware of ADs for life-sustaining treatment were 4.32 times more likely to intend to complete ADs(OR 4.32, 95% CI 1.59-11.70) compared to those who were not aware. No other variables showed statistically significant results. Conclusion An analysis of the factors related to the intention to complete an advance directive for life-sustaining treatment among middle-aged adults aged 50 to 64 revealed no significant associations with socioeconomic characteristics, health-related factors, awareness of life-sustaining treatments, or experiences of bereavement. However, awareness of advance directives was found to be crucial for increasing the intention to complete one. Advance directives for life-sustaining treatment are essential in an aging society as they help reduce the social costs associated with life-sustaining treatments, minimize communication conflicts between patients and their families, and ensure a dignified death. Therefore, to enhance awareness and completion rates of advance directives and establish them as a cultural norm, it is necessary to expand public promotion and education about the terminology and content of advance directives for life-sustaining treatment.

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

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.

혈액투석 환자 대상 연명의료 교육이 사전연명의료의향서 지식과 태도에 미치는 영향

정소영 중앙대학교 건강간호대학원 2024 국내석사

우리사회가 고령화됨에 따라 건강히 삶의 영위하는 것뿐만 아니라 스스로 삶의 마지막을 준비하는 것 또한 중요해지고 있다. 환자의 생애 마지막 치료에 대한 자기결정권을 보호하고 존중하는 취지인 연명의료결정법에서 의식이 명료한 평상시 명확한 의사 표현을 할 수 있는 사전연명의료의향서는 매우 중요하다. 이 연구는 고령과 만성질환을 복합적으로 가지고 있는 혈액투석 환자를 대상으로 연명의료 교육을 제공하고 사전연명의료의향서의 지식과 태도 및 작성의도의 변화를 파악하는데 목적을 두었다. 자료 수집은 2024년 3월 27일부터 2024년 4월 15일까지 이루어졌으며 서울의 일개 종합병원 인공신실에서 혈액투석을 받고 있는 30명의 환자를 대상으로 환자 1명 대 교육자 1명으로 구성하여 교육 전 설문지 15분, 이론교육 20분, 교육 일주일 후 설문지 15분으로 운영되었다. 자료 분석은 IBM SPSS 29.0 통계 프로그램을 이용하여 대상자의 일반적 특성 및 각 변수는 빈도 및 백분율, 평균과 표준편차를 이용하여 분석하였다. 교육 전·후 사전연명의료의향서에 대한 지식, 태도는 Independent t-test, Mann-Whitney test, Wilcoxon signed rank test를 이용하여 검정하였으며, 사전연명의료의향서에 대한 작성의도는 χ2-test 통해 분석하였다. 연명의료 교육에 대한 만족도는 평균 및 표준편차를 이용하여 분석하였다. 분석결과를 정리하면 다음과 같다. 1. 사전연명의료의향서에 대한 지식은 교육 전 평균 11.73±3.49점에서 교육 후 평균 14.60±2.96점으로 통계적으로 유의하게 높아졌다. 2. 사전연명의료의향서에 대한 태도는 교육 전 평균 2.66±0.36점에서 교육 후 평균 2.72±0.44점으로 통계적으로 유의하지는 않았다. 3. 사전연명의료의향서에 대한 작성필요성은 긍정적인 의견이 교육 전 66.7%에서 교육 후 86.7%로 증가하고, 작성의지도 긍정적인 의견이 교육 전 63.3%에서 교육 후 73.3%로 증가하였으나 유의미하게 긍정적 변화가 확인되지 않았다. 4. 교육만족도는 4점 만점에 평균 2.98±0.30점으로 나타났다. 본 연구는 혈액투석 환자를 대상으로 연명의료 교육을 시행하고, 사전연명의료의향서에 대한 지식, 태도 및 작성의도의 효과를 비교하여 건강한 혈액투석생활을 지속하면서 긍정적인 생애말기 치료방향을 준비하는데 도움을 주었다는데 의의가 있다. 다만, 진행한 연명의료 교육에 대한 지속적인 효과평가 검증이 필요하며, 이를 바탕으로 추후 교육 자료를 보완하여 다른 질환 환자의 연명의료 관련 교육에도 활용하여 연구의 범주를 확대할 필요가 있다고 본다. As our society ages, it becomes increasingly important not only to maintain a healthy life but also to prepare for the end of life. In the Life Sustaining Treatment Decision Act, which is intended to protect and respect a patient's right to self-determination regarding end-of-life treatment, an advance directive for life-sustaining treatment that allows patients to express their opinions clearly during normal times is very important. This study aims to provide education on life-sustaining treatment to hemodialysis patients with complex conditions of old age and chronic diseases, and to identify changes in knowledge, attitudes, and intention to complete an advance directive for life-sustaining treatment. Data collection was conducted from March 27, 2024, to April 15, 2024, involving 30 hemodialysis patients at an artificial kidney room in a general hospital in Seoul. The education was structured as one-on-one sessions, consisting of a 15-minute pre-education survey, 20 minutes of theoretical education, and a 15-minute post-education survey conducted one week later. Data analysis was performed using IBM SPSS 29.0, with general characteristics and each variable analyzed using frequency and percentage, mean, and standard deviation. Knowledge and attitudes toward advance directives for life-sustaining treatment before and after education were tested using Independent t-test, Mann-Whitney test, and Wilcoxon signed rank test, while the intention to complete an advance directive was analyzed using the χ2-test. Satisfaction with the education on life-sustaining treatment was analyzed using mean and standard deviation. The summarized results are as follows: 1. Knowledge about advance directives for life-sustaining treatment significantly increased from a pre-education mean score of 11.73±3.49 to a post-education mean score of 14.60±2.96. 2. Attitudes toward advance directives for life-sustaining treatment showed a non-significant increase from a pre-education mean score of 2.66±0.36 to a post-education mean score of 2.72±0.44. 3. The perceived necessity of completing an advance directive for life-sustaining treatment increased from 66.7% pre-education to 86.7% post-education, and the intention to complete the directive increased from 63.3% pre-education to 73.3% post-education, although these changes were not statistically significant. 4. Satisfaction with the education was mean score of 2.98±0.30 on a 4-point scale. This study is significant in that it provided education on life-sustaining treatment to hemodialysis patients, comparing the effects on knowledge, attitudes, and intention to complete an advance directive, thereby helping patients maintain a healthy hemodialysis lifestyle while preparing for positive end-of-life treatment decisions. However, continuous evaluation of the long-term effectiveness of the provided education on life-sustaining treatment is needed. Based on this, future educational materials should be supplemented and applied to life-sustaining treatment education for patients with other diseases, thereby expanding the scope of the research.

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.

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.