背景：
安寧緩和醫療起初是為癌症患者所發展，過往數據也發現到癌症患者接受安寧療護的比率遠高於非癌症患者，這類情況亦可能出現在同一器官的癌症與非癌症患者間。研究期間適逢2020 年 3 月爆發新冠肺炎 (COVID-19) 疫情引起對於臨終關懷議題的關注。類似情況亦可能出現在同一器官的癌症與非癌症患者間。末期肝癌與肝硬化患者通常由相同專科照護，但肝癌患者通常較容易獲得安寧緩和醫療 (Hospice Palliative Care , HPC) 的服務。本研究探討 COVID-19 疫情的嚴重程度以及相關因素如何影響末期肝癌與肝硬化患者使用安寧服務的情況。
方法：
本研究收集 2017 年 1 月至 2023 年 2 月間於南部某公立醫學中心死亡的末期肝癌 (ICD-10 診斷碼 C22) 與肝硬化 (ICD-10 診斷碼 K70 至 K76) 患者資料。具有不施行心肺復甦術 (DNR) 醫令的患者為經醫師確認的末期狀態患者。COVID-19 疫情分期根據台灣衛生福利部的報告分為3個階段，無疫情（2017 年 1 月1日至 2020 年 2 月28日）；疫情初期（2020 年 3 月 1 日至 2021 年 3 月 31 日）：早期階段，確診病例數有限；疫情爆發期（2021 年 4 月 1 日至 2023 年 2 月 28 日）：以 Delta 與 Omicron 變異株為主的社區群聚流行期。統計分析包括卡方檢定 (chi-square test)、t 檢定、單因子變異數分析 (one-way ANOVA)，以及羅吉斯迴歸分析 (logistic regression)與負二項式迴歸(negative binomial regression)。
結果：
本研究納入 796 名住院死亡的末期肝癌與肝硬化患者，兩類患者在疫情分期的比例分佈為末期肝硬化患者（無疫情107人、疫情初期49人、疫情爆發期22人）；末期肝癌患者（無疫情371人、疫情初期179人、疫情爆發期68人）。安寧服務使用率在肝癌與肝硬化患者之間顯著不同（72.7% vs. 43.82%，p < 0.001）。疫情爆發後，安寧服務使用率顯著增加（疫情前 61.51% vs. 疫情期間 73.27%，p = 0.001）。羅吉斯迴歸分析顯示，肝癌診斷、兩個疫情階段、具有榮民身份以及重大傷病證明均與 HPC 使用呈正相關。相反地，男性性別與加護病房住院則與安寧服務使用呈負相關。
結論：
本研究強調了末期肝癌與肝硬化患者之間安寧服務使用率的顯著差異，並指出在 COVID-19 疫情期間，末期肝病患者的安寧服務使用率有所增加。這些結果可能是大眾還存有安寧服務對象為末期癌症患者的誤解，肝硬化患者可能不知道簽署DNR後可以接受安寧服務，關於安寧緩和醫療的政策已近乎完備，可能機構沒有落實推動，且在臨床處置上在非肝癌患者些不同之故，加上新冠疫情的爆發等的原因，為政策制定者在應對公共衛生危機時提供了重要的參考。

Introduction:
Palliative care was originally developed for cancer patients, and historical data indicate that cancer patients receive hospice care at a significantly higher rate than non-cancer patients. A similar pattern may also be observed among patients with cancerous and non-cancerous conditions affecting the same organ.During the study period, the outbreak of COVID-19 in March 2020 heightened awareness of end-of-life care. Terminal liver cancer and liver cirrhosis patients are typically managed by the same specialized medical teams; however, liver cancer patients generally have greater access to Hospice Palliative Care (HPC).This study explores how the severity of the COVID-19 pandemic, along with other contributing factors, influenced the utilization of palliative care services among terminal liver cancer and liver cirrhosis patients.
Methods:
Data were collected on deceased liver cancer (ICD-10 code C22) and cirrhosis (ICD-10 codes K70 to K76) patients at a public medical center in southern Taiwan between January 2017 and February 2023. Patients with Do-Not-Resuscitate (DNR) orders were classified as having physician-identified terminal status. The COVID-19 pandemic phases were classified based on reports from Taiwan's Ministry of Health and Welfare and divided into three stages:Pre-pandemic period (January 1, 2017 – February 28, 2020): No reported COVID-19 cases. Early pandemic phase (March 1, 2020 – March 31, 2021): Initial stage with a limited number of confirmed cases. Pandemic outbreak phase (April 1, 2021 – February 28, 2023): Widespread community transmission, primarily driven by the Delta and Omicron variants. Statistical analyses included the chi-square test, t-test, one-way analysis of variance (ANOVA), logistic regression, and negative binomial regression.
Results:
The study included 796 hospitalized deceased patients with terminal liver cancer and cirrhosis .The distribution of patients across different pandemic phases was as follows: Terminal liver cirrhosis patients: Pre-pandemic (107), early pandemic (49), and pandemic outbreak phase (22)；Terminal liver cancer patients: Pre-pandemic (371), early pandemic (179), and pandemic outbreak phase (68).
HPC utilization differed significantly between liver cancer and cirrhosis patients (72.7% vs. 43.82%, p < 0.001). HPC use also increased significantly after the COVID-19 outbreak (61.51% pre-pandemic vs. 73.27% during the pandemic, p = 0.001). Logistic regression analysis showed that a cancer diagnosis, both pandemic phases, veterans, and a catastrophic illness certificate were positively associated with HPC utilization. Conversely, male gender and ICU admission were negatively associated with HPC use.
Conclusions
This study highlights a significant disparity in HPC utilization between liver cancer and cirrhosis patients, with increased HPC use among terminal liver disease patients during the COVID-19 pandemic. These findings suggest that misconceptions persist, with the public continuing to associate hospice care primarily with terminal cancer patients. Liver cirrhosis patients may be unaware that they are eligible for HPC after signing a do-not-resuscitate (DNR) order. Although Taiwan’s palliative care policies are nearly comprehensive, gaps in institutional implementation remain, and clinical management for non-cancer patients may differ from that for liver cancer patients. Furthermore, the COVID-19 outbreak may have further shaped these trends .These insights offer valuable guidance for policymakers in addressing public health challenges and enhancing access to end-of-life care.

論文審定書i
致謝ii
中文摘要iii
Abstractv
第一章 緒論1
第一節 研究背景與動機1
第二節 研究目的與研究重要性4
第二章 文獻探討5
第一節 安寧緩和醫療起源與演變5
第二節 臺灣安寧緩和醫療的發展6
第三節 新冠疫情下的安寧發展8
第四節 末期病人接受安寧緩和醫療之影響因素10
第五節 安寧療護對於末期肝臟疾病之患者的影響11
第六節 末期肝臟疾病12
第七節 醫學名詞解釋15
第八節 文獻綜合小節16
第三章 研究方法17
第一節 研究設計與研究架構17
第二節 研究對象與資料來源18
第三節 研究假設21
第四節 研究變項與操作型定義21
第五節 資料處理與分析方法24
第四章 資料分析結果26
第一節 研究對象基本特性26
第二節 連續變項比較分析結果28
第三節 類別變項比較分析結果33
一、人口學資料與臨床醫療資料卡方檢定結果33
二、 肝癌與肝硬化患者在人口學資料及臨床醫療資料特性之卡方檢定結果37
三、 有無接受安寧服務與人口學資料及臨床醫療資料之卡方檢定結果39
第四節 羅吉斯迴歸分析40
第五節 負二項式迴歸分析42
第五章 討論與建議44
第一節研究假設驗證45
第二節研究討論46
第三節 實務含義51
第四節 研究限制與優點51
第五節 後續討論相關建議52
參考資料54
附錄60
附錄1：安寧緩和醫療服務健保給付方式60
附錄2：人體研究計畫同意函63
附錄3：資料所抓取的ICD疾病分類碼(International Statistical Classification of Diseases,ICD)64
附錄4：安寧住院支付標準67
附錄5：榮民於輔導體系醫院的就醫優惠69

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