Korean Journal of Adult Nursing (Korean J Adult Nurs) Vol. 27. 4, 449-458, August 2015 ISSN 1225-4886 (Print) / ISSN 2288-338X (Online) http://dx.doi.org/10.7475/kjan.2015.27.4.449 노인암환자의사전의사결정에대한태도와관련요인 이민혜 1 박연환 2 서울대학교간호대학 1, 서울대학교간호대학 간호과학연구소 2 Factors Influencing Attitude toward Advance Directives of Older Cancer Patients Lee, Min Hye 1 Park, Yeon-Hwan 2 1 College of Nursing, Seoul National University, Seoul 2 College of Nursing, The Research Institute of Nursing Science, Seoul National University, Seoul, Korea Purpose: The aims of this study were to identify the reported attitudes of older patients with cancer toward advance directives (ADs) and the factors associated with their attitudes toward ADs. Methods: The design was a cross-sectional survey. The age mean of the 130 participants were 70.8, and 66.2% of the participants were male. The data were collected at one university hospital in Seoul, South Korea during the period from October 1 st to December 5 th in 2013. The data collecting instruments were the Advance Directives Attitude Survey (ADAS) and questionnaires including socio-demographic and disease-related characteristics, family function. Results: 30.0% of the participants were aware of ADs, only 9% of them had been informed by healthcare providers. Most participants (93.1%) intended to complete ADs. The mean score of ADAS was 48.29. The stepwise linear regression analysis indicated that family function, perceived health status, period of education, and age accounted for a significant percentage (52.0%, p<.001) of the variance in participants ADAS. The variable with the greatest effect was family function. Conclusion: The findings suggest that family function and attitude of older cancer patients need to be considered for adapting ADs to Korean health care systems. Healthcare providers should include family members in advanced care planning discussions. Key Words: Advance directives, Advance care planning, Aged, Cancer, Family 서론 1. 연구의필요성 2012년우리나라국가암등록통계에따르면 5년암생존율이 65% 를넘어서고, 5년암생존자중 35% 이상이 65세노인암환자이다. 의료기술의비약적발전으로암환자의생존 율은증가하였지만, 말기암환자의고통스러운삶을본인의지와무관하게무의미하게연장시키는부정적인결과도초래하였다. 무의미한연명치료는암환자의사망전 3개월간의료비가연간의료비의절반이상을차지할만큼가족에게경제적부담이되고 [1], 삶의질과존엄성에대한논란을일으키기도하였다 [2]. 최근우리나라노인은무의미한연명치료를중단하기를원하고, 나아가치료결정과정에적극적으로참여하 주요어 : 사전의사결정, 사전의료계획, 노인, 암, 가족 Corresponding author: Park, Yeon-Hwan College of Nursing, Seoul National University, 103 Daehak-ro, Jongno-gu, Seoul 110-799, Korea. Tel: +82-2-740-8803, Fax: +82-2-765-4103, E-mail: hanipyh@snu.ac.kr - 이논문은제1저자이민혜의석사학위논문축약본임. - This manuscript is a condensed form of the first author' master's thesis from Seoul National University. Received: Jun 8, 2015 / Revised: Aug 16, 2015 / Accepted: Aug 16, 2015 This is an open access article distributed under the terms of the Creative Commons Attribution n-commercial License (http://creativecommons.org/licenses/ by-nc/3.0), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. c 2015 Korean Society of Adult Nursing Vol. 27http://www.ana.or.kr. 4, 2015 449
이민혜 박연환 고자하여연명치료선택에대한대상자의자율성, 자기결정권에대한인식이증가하고있다 [3,4]. 그럼에도불구하고, 아직까지우리나라에서는임종이임박하였을때가족과의료진이결정을내리고있어대상자의자율성을침해하고, 가치중심적판단이요구되기때문에본인의의사를모르고가족이결정할경우의견일치가어렵고여러문제나갈등이생길수있다 [2,5]. 이같은문제에대한대안으로대상자의자기결정권을보호하는사전의사결정에대한관심이증가하고있으며 [3,4], 환자가직접사전의사결정에참여하는사회적분위기조성이필요하다 [5]. 사전의사결정은의사표현이불가능할때를대비하여자신이원하거나원하지않는의료행위에대해서사전에결정하는것을의미한다 [6]. 사전의사결정은궁극적으로대상자의자율성을보호하고, 불필요한연명치료를예방하여가족들의경제적부담감도완화시켜준다 [7]. 선진국에서는사전의사결정을활성화하기위해법과제도를도입하였으나, 우리나라는논의를시작하여연명치료중단과관련된법안과정책에대해합의및조율을하고있는상태이다. 한국간호사윤리강령에서는대상자의연명치료, 자기결정권과관련하여간호사에게요구되는덕목을언급하고있으며, 보건복지부는 2010년연명치료중단제도화와관련하여연명치료중단대상, 사전의료의향서작성조건및절차에대한합의안을제시하였다. 그이후 2013년 11월공청회를통해서연명의료결정법 ( 안 ) 초안을발의한상태이다. 외국에서는 1990년대부터입원, 외래환자 [8] 을시작으로지역사회재가노인 [9,10], 가족 [11] 등다양한대상자들에대해사전의사결정에대한태도 [12], 지식과영향요인 [13] 등사전의사결정의정착과활성화를위한다양한연구가이루어졌다. 우리나라에서는주로 2000년이후일반인 [14], 성인 [15] 을대상으로사전의사결정의현황, 지식이나선호도등을확인하는연구가이루어졌다. La Puma 와 Silverstein 의연구에서심폐소생술금지대상의 85% 가암환자였으며 [16], 최근우리나라노인도사전의사결정제도를찬성하거나선호하는것으로나타나 [4], 노인암환자는사전의사결정제도가도입되면직접적인대상자가될가능성이높지만이에대한연구는부족한실정이다. 노인암환자는 암 이라는질병특성과생애말기라는시기가맞물려임종이나연명치료에대해서고려하였을가능성이높고, 잦은입원으로의료현장에노출된경험이많기때문에노인암환자의사전의사결정에대한태도를확인하는연구는매우중요하다. 또한의학적의사결정과정은문화와지역에따라다르게나타나다른접근방법이요구되기때문에 [17], 우리나라노인암환자의사전의사결정에대한태도에영향을미치는요인을규명하여우리나라사회의현실과특성을반영한사전의사결정체제를구축하여야한다 [5]. 국외선행연구결과에따르면, 질환의중증도가높을수록, 시설거주기간이길수록, 사전의사결정을하는비율이높았고, 성별, 연령, 학력, 종교가사전의사결정이행의중요한요인이었다 [13]. 또한지각하는건강상태가사전의사결정에대한태도에영향을미치는것으로나타났다 [15]. 특히, 노인은사전의사결정에대해고려할때 가족 을중요한요인으로생각하며 [18], 한국계미국노인은생의말치료결정을가족의책임으로여겨다른인종집단에비해서가족중심의사결정을선호하는것으로나타났다 [19]. 아시아문화권에서는의학적의사결정과정에서의역할선택이나사전의사결정에대한선호도와관련된요인으로서가족기능이중요한요인으로간주되는데 [15], 실제로일본의선행연구에서가족기능이사전의사결정에대한태도와관련이있는것으로보고되었다 [20]. 그러므로가족중심문화를반영한한국형사전의사결정제도구축하기위해서는국내노인암환자의가족기능과사전의사결정에대한태도간의관련성을확인할필요가있다. 본연구는노인암환자의사전의사결정에대한태도를알아보고, 이에영향을미치는가족기능등의관련요인을규명함으로써가족중심문화를반영한한국형사전의사결정제도구축에대한기초자료를제공할수있을것으로기대된다. 2. 연구목적본연구의목적은노인암환자의사전의사결정에대한태도를파악하고, 이에영향을미치는요인을규명하는데있다. 구체적인목적은다음과같다. 노인암환자의사전의사결정에대한태도를파악한다. 노인암환자의특성에따른사전의사결정에대한태도의차이를확인한다. 노인암환자의특성, 가족기능이노인암환자의사전의사결정에대한태도에미치는영향을확인한다. 연구방법 1. 연구설계본연구는노인암환자의사전의사결정에대한태도에영향을미치는요인을확인하고자하는서술적조사연구이다. 450 Korean Journal of Adult Nursing
노인암환자의사전의사결정에대한태도와관련요인 2. 연구대상연구대상은대도시소재대학병원의외래를내원하거나입원치료를받고있는 65세이상노인암환자이다. 표본의크기는단계적회귀분석시유의수준 5% 와검정력 80%, 효과크기는중간수준인 0.15 및독립변수는 6개 ( 국외선행연구에서관련요인으로보고된연령, 성별, 학력, 종교, 지각된건강상태와본연구에서중요변수인가족기능을주요예측변수로판단함 ) 로설정하여 G*Power 3.1 프로그램을이용하여산정한결과, 최소표본의크기는 98명으로나타났다. 탈락률을고려하여 130명을대상으로편의표출하여외래 89명, 입원 41명의총 130명이설문을완료하여설문지회수율은 100% 였다. 구체적인선정기준은의식이명료하고의사소통이가능한암진단사실을알고있는만 65세이상의노인암환자중연구의목적을이해하고연구참여에동의한자이다. 노인암환자는외래방문과입원이잦으므로일반화를위해서외래환자와단기시술및항암치료를위해서입원하여일주일이내로퇴원계획이있는입원환자를대상자로하였다. 자료수집에영향을미칠수있으므로 K-MMSE (Mini Mental Status Examination in the Korean version) 로평가하여 23점이하로인지장애가의심되는경우제외하고자하였으나, 조사결과제외된대상자는없었다. 3. 연구도구 1) 사전의사결정에대한태도사전의사결정에대한태도를측정하는도구는 lan 과 Bruder [8] 가만든 Advance Directive Attitude Scale (ADAS) 를동일저자가 2003년에수정및보완한것을 Lee와 Park [21] 이번역한것으로써 4점척도의총 16개문항이다. 점수가높을수록사전의사결정에대한태도가긍정적이라고할수있다. 도구의신뢰도는개발자의연구에서 Cronbach s 는.74 였고 Lee와 Park [21] 의연구에서는.79, 본연구에서의신뢰도는 Cronbach s 는.79였다. 2) 대상자의특성문헌고찰결과사전의사결정과관련이있을것으로예상되는성별, 연령, 학력등의인구사회학적특성과지각된건강상태, 의료비지불자, 암의종류, 진단시기, 병식획득시기, 치료기간등의질병관련특성, 사전의사결정에대해서들어본경험, 사전의사결정에대해서알고있는지유무등의사전의사 결정과관련된특성을수집하기위해 17개문항의구조화된설문지로구성하였다. 지각된건강상태는 0~10점의시각적상사척도 (Visual Analogue Scale, VAS) 를이용하여스스로건강상태를평가하는방법으로측정하며, 점수가높을수록지각된건강상태가좋은것을의미한다. 3) 가족기능가족기능은역동적인가족체계를사정할수있는도구인 Olson, Portner와 Lavee [22] 가개발한 Family Adaptability & Cohesion Evaluation Scale-III (FACES-III) 를 Kim과 Moon [23] 이한국어로번역및수정한도구를사용하여측정하였다. 하위영역인응집성, 적응성에관련되어각 10개씩총 20 문항으로구성되어있으며 5점척도로점수가높을수록응집성과적응성이좋음을의미한다. 이도구의타당도와신뢰도는 Olson의연구에서 Cronbach s 는.92로나타났고 [22], Kim 과 Moon의연구에서는.78[23], 본연구에서의신뢰도는.90 이었다. 4. 자료수집자료수집은 2013년 10월 1일부터 12월 5일까지연구에대한목적과설명을듣고자발적으로연구참여에동의하고, K-MMSE로인지기능장애가없는지확인한후설문내용에대한이해도를높이기위해서일대일설문조사로진행하였다. K-MMSE 23점이하로인지기능장애가없는지확인후사전의사결정에대하여알고있거나들어본적이있는지먼저확인하고전혀들어본적이없는대상자에게는구조화된간단한정보를제공한후설문조사를시작하였다. 본설문조사는연구자본인과간호사 2명, 간호대학생 3명을자료수집원으로모집하여연구도구및사전의사결정에대해설명하고, 설문조사방법및주의사항에대하여교육한후실시하였다. 6명자료수집자의평가자간신뢰도 (inter-rater reliability) 는.90이었다. 5. 윤리적고려 S병원연구대상자보호심사위원회의승인 (H-1307-003-499) 을받았으며, 해당병원간호본부의논문자료수집승인을받은후연구를수행하였다. 연구윤리심의위원회의승인을받은동의서를사용하였으며, 대상자에게연구목적및익명성보장등을설명하고도중에라도참여를철회할수있음을알리고 Vol. 27. 4, 2015 451
이민혜 박연환 자발적인서면동의받은후설문조사를실시하였다. 암진단사실을모를경우에대비하여, 설문조사전외래를방문한이유를물어병식을확인하고, 입원환자의경우입원시수집하는간호정보조사지의병식에대한내용을먼저확인하였다. 수집한내용은숫자로암호화하여연구자만사용하는컴퓨터에문서및파일을안전하게보관하였다. 6. 자료분석수집된자료는 SPSS/WIN 21.0 프로그램을이용하여다음과같이분석하였다. 노인암환자의사전의사결정에대한태도는비율, 평균등기술통계로산출하였다. 노인암환자의특성에따른사전의사결정에대한태도의차이는 t-test, one way ANOVA를통해서검정하였다. One way ANOVA 검정시유의한결과는등분산인경우 Scheffe s test로, 등분산이아닌경우는 welch 검정을하고 Dunnett T3 test로사후분석을실시하였다. 노인암환자의사전의사결정에대한태도에영향을미치는요인은 Pearson s correlation 로상관관계를검정하고, 관련요인의설명정도를확인하기위해서명목변수는더미변수로변환하여단계적회귀분석 (Stepwise linear regression) 을실시하였다. 연구결과 1. 대상자의특성대상자의특성은 Table 1과같다. 남자가 86명 (66.2%) 이었으며, 연령은평균 70.8세로 65~74세가가장많았다. 학력은대졸이상이 31.5% 로가장많았고, 동거가족수는평균 1.58 명이었다. 암종별로는간담췌계통암환자가 75.4% 로가장많았으며, 암을진단받은시기는평균 48.36개월전이었으며, 대상자가자신의암발생을알게된시기가이와유사하였다 (48.36±55.22). 의료비지불자는 56.2% 가본인이었으며, 지각된건강상태는평균 6.18점이었다. 사전의사결정에대해서들어본경험이있었던대상자는 33.1% 였는데, 의료진을통해서접한대상자 (9.0%) 가가장적었다. 기회가된다면사전의사결정을할의사가있는대상자는 93.1% 였으며, 사전의사결정을할때가족과꼭상의하겠다는경우가 62.3% 로가장많았으며상의할가족으로배우자 (44.5%) 를가장많이선택하였다. Table 1. Characteristics of the Subjects (N=130) Characteristics Categories n(%) or M±SD Gender Male 86(66.2) Female 44(33.8) Age (year) Spouse Level of education Religion Living with Medical expenses payment Cancer site Period since cancer diagnosis (month) Period of medical treatment (month) Perceived health status Listen about ADs Route of informed about ADs (N =43) Awareness of ADs Intention to ADs Preferred type of decision about ADs Family member to discuss about ADs 65~74 75 Having t having ne Elementary school Middle school High school University Alone Spouse Spouse & children Children Others Self Children Self + Children HPB Gastroenteric Urinary 0~11 12~35 36~59 60~83 84 0~11 12~35 36~59 60~83 84 0~3 4~7 8~10 Healthcare provider Broadcast media Surrounding people Others Make one's own decision Discuss with family Discuss with family when necessary Spouse Children Brother and Sister All family Others ADs=Advance Directives; HPB=Hepatopancreaticobiliary; Duplicated answer. 70.75±5.09 98(75.4) 32(24.6) 114 (87.7) 16(12.3) 10 (7.8) 18(13.8) 23(17.7) 38(29.2) 41(31.5) 97(74.6) 33(25.4) 14(10.8) 71(54.6) 35(26.9) 6(4.6) 4(3.1) 73(56.2) 32(24.6) 25(19.2) 98(75.4) 21(16.1) 11 (8.5) 48.36±55.40 35(27.0) 32(24.6) 18(13.8) 19(14.6) 26(20.0) 46.96±54.43 36(27.7) 32(24.6) 17(13.1) 20(15.4) 25(19.2) 6.18±1.78 7(5.4) 98(75.4) 25(19.2) 43(33.1) 87(66.9) 4(9.0) 27(61.4) 8 (18.2) 5 (11.4) 39(30.0) 91(70.0) 121 (93.1) 9(6.9) 24(18.5) 81(62.3) 25(19.2) 61(44.5) 35(25.5) 1(0.8) 38(27.7) 2(1.5) 452 Korean Journal of Adult Nursing
노인암환자의사전의사결정에대한태도와관련요인 2. 대상자의사전의사결정에대한태도와가족기능 3. 대상자의특성에따른사전의사결정에대한태도의차이 본연구에참여한노인암환자의사전의사결정에대한태도는평균 48.29점이었다. 문항별로가장긍정적인점수를보인항목은 사전의사결정은나의가족이나를돌보는것에대한부담을덜어주는역할을할것이다, 사전의사결정을하는것은내가건강할때하는것이더좋을것같다 이었으며, 가장부정적인항목은 나는이미생의말기에받을치료에대해서선택해두었다 였다 (Table 2). 본연구에참여한노인암환자의가족기능은평균 75.51±11.13 점이었다 (Table 2). 인구사회학적특성중연령과학력에따라사전의사결정에대한태도에유의한차이가있었다 (p<.001). 사후분석에서 75세이상보다 65~74세대상자가, 초졸이하에비해서대졸이상대상자가사전의사결정에대한태도가긍정적인것으로나타났다. 그외성별, 배우자유무, 독거유무, 가족형태에따른사전의사결정에대한태도는유의한차이가없었다 (Table 3). 질병관련특성중에서는의료비지불자 (p=.004) 와지각된건강상태 (p<.001) 에따라사전의사결정에대한태도에 Table 2. Attitude toward ADs and Family Function of the Subjects (N=130) Variables Items M±SD Attitude Having an ADs would make my family feel left out of caring for me. 3.32±0.56 toward ADs It is better to make an advance directive when you are healthy. 3.32±0.58 Having an ADs would make sure that my family knows my treatment wishes. 3.30±0.55 Making my end of life treatment wishes clear with an ADs would keep my family from disagreeing over what to do if I were very sick and unable to decide for myself. 3.19±0.64 Having an ADs would make sure that I get the treatment at the end of my life that I do want. 3.18±0.61 If I could not make decisions, my family would be given choices about the treatment I would receive. 3.17±0.64 Having an ADs would prevent costly medical exposures for my family. 3.15±0.65 I trust one of my family or friends to make treatment decisions for me if I cannot make them myself. 3.13±0.66 Making my end of life treatment wishes clear with an ADs would help to prevent guilt in my family. 3.12±0.70 My doctor would include my concerns in decisions about my treatment at the end of life. 3.08±0.70 I am not sick enough to have an ADs. 2.97±0.74 I would be given choices about the treatment I would receive at the end of my life. 2.96±0.71 I think my family would want me to have an ADs. 2.69±0.85 My family wants me to have an ADs. 2.64±0.79 Making my end of life treatment wishes clear with an ADs would have no impact on my family. 2.60±0.84 I have choices about the treatment I would receive at the end of my life. 2.48±0.95 Total Mean 3.02±0.75 Total Sum 48.29±5.57 Family function Cohesion 39.36±6.84 Adaptability 36.15±5.74 Total Sum 75.51±11.13 ADs=advance directives; Reverse score. Vol. 27. 4, 2015 453
이민혜 박연환 유의한차이가있었다. 사후분석에서의료비부담을본인이하거나자녀와함께한경우가자녀가의료비를모두부담하는경우보다태도가유의하게긍정적이었다. 그리고지각된건강상태를 3점이하로평가한경우가 4점이상으로평가한대상자에비해서태도가유의하게부정적이었다. 그외에암의종류, 진단시기에따른사전의사결정태도는유의한차이가없었다 (Table 3). 사전의사결정에대해서들어본경험, 사전의사결정에대해서아는지유무, 사전의사결정에대해접한경로, 사전의사결정의사유무, 선호하는사전의사결정형태등의사전의사결정과관련된특성에따른사전의사결정에대한태도에유의한차이가없었다 (Table 3). 4. 사전의사결정에대한태도에영향을미치는요인사전의사결정에대한태도와유의한상관관계를보이는요인은가족기능, 연령, 학력, 지각된건강상태, 진단시기, 병식획득시기, 치료기간이었다. 가족기능 (r=.63, p<.001), 지각된건강상태 (r=.54, p<.001), 학력 (r=.47, p <.001), 진단시기 (r=.23, p =.009), 병식획득시기 (r=.22, p =.011), 치료기간 (r=.21, p =.018) 이사전의사결정에대한태도와정적상관관계가있었다. 연령은부적상관관계 (r=-.35, p <.001) 가있었다 (Table 4). 상관관계가있는변수들중에서사전의사결정에대한태도에영향을미치는요인을확인하기위해서단계적회귀분석을시행하였다. 변수는상관관계에서유의하였던가족기능, 지각한건강상태, 연령, 학력, 진단시기와단변량분석에서유의했던의료비지불자를선정했으며, 병식획득시기와치료기간은진단시기와상관관계가.8 이상으로변수간의공선성을제거하기위해서제외하였다. 학력은연도로변환하고, 명목척도인의료비지불자는더미변수로변환하여분석하였으며, 단계선택의기준은입력할 F의확률.05 이하, 제거할 F의확률.10 이상이었다. 분석결과, 변수간의상관계수가.8 이상인경우는없었으며, 회귀분석의가정을검정한결과모두충족하는것으로나타났다. Durbin-Watson test를통해도출된통계량은 1.956으로 2에가까워서잔차의독립성가정을만족하였다. 다음으로공차한계는 0.68~0.93 로 0.1 이하의값이없고, 분산팽창인자는 1.08~1.46으로 10보다크지않으므로다중공선성문제가없었다. Cook s D 통계량은평균 0.007, 최대값 0.046, 최소값 0.000으로이상점이없었다. 회귀분석을한결과의료비지불자와진단시기가제외된 4개의변수에의한 회귀모형이유의한것으로나타났다 (F=35.29, p<.001). 모형의설명력 (Adj. R 2 ) 은.52였고, 사전의사결정에대한태도에가장큰영향을미치는요인은가족기능 (β=.39, p<.001) 으로확인되었다 (Table 5). 논의본연구는노인암환자의사전의사결정에대한태도와관련된요인을규명함으로써서구의철학이담긴제도가아닌우리나라의사회문화적현실과특성을반영한사전의사결정제도를구축하는데기초자료로써의의의가있다. 연구에참여한대상자의 93.1% 가사전의사결정을할의사가있었는데, 이는선행연구에서복지관이용노인의 61.1% [21], 지역사회노인의 55.2%[4] 가사전의사결정을찬성하거나의사가있다고한것에비해매우높은비율이었다. 이러한결과는지역사회노인에비해노인암환자가사전의사결정을더현실적으로인식하기때문인것으로사료된다. 이는 Hanson 과 Rodgman[25] 의연구에서죽음에가까운대상자가생전유언을더많이하며, 암환자의사전의사결정이행률이 16.4% 인데비해서당뇨등만성질환을가진환자는 10% 이하로상대적으로낮았던결과와유사하다. 그러므로사전의사결정제도가도입되면노인암환자가직접적인대상자가될가능성이높다. 국외연구에의하면사전의사결정에대한태도가이행과관련이있다고보고되어 [10], 우리나라에서도제도의정착과활성화를위해서사전의사결정에대한대상자의태도를고려해야한다. 연구결과노인암환자의사전의사결정에대한태도는평균 48.29±5.57 점으로대체로긍정적이었다. 사전의사결정에대한태도평가항목중가장점수가높았던항목은 사전의사결정은가족이나를돌보는것에대한부담감을덜어줄것이다 와 사전의사결정은내가건강할때하는것이더좋다 이었다. 이를통해서연구에참여한노인암환자는건강할때사전의사결정을하는것을선호하며, 사전의사결정이가족의돌봄부담감을덜어줄것이라는믿음이있음을알수있다. 이는질병이악화되기전초기에사전의사결정을내리길선호한다는선행연구와일치한다 [21]. 반면, 나는앞으로생의말기에받을치료를선택할기회가있을것이다. 항목은평균 2.96±0.71 점으로다른항목에비해서점수가낮았다. 같은도구로사전의사결정에대한태도를측정한 Douglas와 Brown[12] 의연구에서는이항목이가장점수가높아서본연구결과와차이가있었다. 이를통해국 454 Korean Journal of Adult Nursing
노인암환자의사전의사결정에대한태도와관련요인 Table 3. Differences of Attitude toward ADs according to Characteristics of the Subjects Characteristics Categories M±SD t or F p Gender Male Female Age (year) 65~74 75 Spouse Having t having Level of education Religion Living with Medical expenses payment Cancer site Period since cancer diagnosis Period of medical treatment Perceived health status Listen about ADs Route of informed about ADs Awareness of ADs Intention to ADs Preferred type of decision about ADs ne a Elementary school a,b Middle school b,c High school b,c University c Alone Spouse Spouse&Children Children Others Self a Children b Self + Children a HPB Gastroenteric Urinary 0~11 12~35 36~59 60~83 84 0~11 12~35 36~59 60~83 84 0~3 a 4~7 b 8~10 b Healthcare provider Broadcast media Surrounding people Others Make one's own decision DWF DWF when necessary 48.52±5.31 47.84±6.08 49.47±5.29 44.69±4.86 48.09±5.38 49.75±6.82 41.70±4.92 45.56±5.14 48.39±4.77 48.08±4.34 51.24±5.50 48.37±5.72 48.06±5.19 46.86±5.35 48.69±5.57 47.63±4.61 46.33±7.34 55.00±8.37 49.29±5.34 45.50±5.39 48.96±5.47 48.77±5.92 46.57±4.59 47.36±3.04 47.40±4.68 46.69±5.49 49.83±5.32 48.63±5.16 50.15±6.69 47.47±4.63 46.88±5.70 49.47±5.25 49.05±5.36 49.88±6.68 39.29±3.40 48.11±5.10 51.52±4.93 47.95±4.73 48.46±5.96 50.75±6.50 47.19±4.53 49.13±5.57 47.80±2.49 48.49±4.50 48.21±5.60 48.40±5.65 46.78±4.27 49.43±41.71 48.21±26.90 46.92±33.21 0.66.511 4.52 <.001-1.12.265 9.45 a<b<c <.001 0.28.783 2.16.078 5.77 a>b.004 1.52.222 2.04.093 1.53.198 16.66 a<b <.001 0.53.600 0.56.725-0.29.771 0.85.400 1.21.300 ADs=advance directives, DWF=discuss with family; HPB=hepatopancreaticobiliary; Mean followed by same letter do not differ significant at post hoc test. (N=130) Vol. 27. 4, 2015 455
이민혜 박연환 Table 4. Correlation among Variables related to the Attitude toward ADs Variables X2 X3 X4 X5 X6 X7 X8 X9 X10 X11 X1.63**.60**.60** -.35**.47**.54**.00.23*.22*.21* X2.95**.94** -.24**.41**.50**.11.14.13.13 X3.79** -.25**.40**.53**.11.10.09.08 X4 -.21*.36**.41**.10.17.16.16 X5 -.20* -.18* -.19* -.07 -.07 -.07 X6.38**.19*.12.12.12 X7.03.13.13.13 X8.01.01 -.01 X9 1.00**.99** X10 99** X1=attitude toward advance directives; X2=family function; X3=cohesion; X4=adaptability; X5=age; X6=period of education; X7=perceived health status; X8=no. of living together family; X9=period since cancer diagnosis; X10=period since informed about illness; X11=period of medical; ADs=Advance Directives; *p<.05, **p<.01. (N=130) Table 5. Associations of Attitude toward Advance Directives with Variables by Stepwise Linear Regression Analysis (N=130) Variables B SE β R 2 t p (Constant) 39.69 5.98 6.64 <.001 Family function (FACE III) 0.20 0.04.39.39 5.30 <.001 Perceived health status 0.78 0.23.25.46 3.41.001 Period of education (year) 0.24 0.09.18.50 0.18.010 Age (year) -0.20 0.07 -.18.53-2.80.006 R 2 =.53, Adjusted R 2 =.52, F=35.29, p<.001 SE=standard errors; Unstandardized coefficients. 내노인암환자는국외대상자들에비해서생의말치료를스스로선택한다는것에대해인식이낮은것을예상할수있다. 이는자율성과관련된문제로한국계미국인이유럽인, 미국인에비해서생의말치료를스스로결정한다는인식이부족하다는선행연구결과와일치한다 [26]. 자율성은스스로결정할기회를갖지못할경우발휘할수없게되므로대상자가자율성을발휘할수있도록사전의사결정제도를활성화해야한다. 한편, 의료비지불자가누구냐에따라서사전의사결정에대한태도에유의한차이가있었다. 본인또는자녀와함께의료비를부담하는경우가자녀가단독으로부담하는경우보다사전의사결정에대한태도가유의하게긍정적이었다 (p=.004). 이는자신의의료비부담이클수록더사전의사결정의필요성을인식하거나의료비지불을타인에게의존하지않는경우자기결정권을좀더행사할수있기때문으로해석할수있다. Lee와 Park[21] 의연구에서도유의하진않았지만의료비지출이많을수록사전의사결정에대한태도가긍정적이었고, 경제수준이좋을수록사전의사결정이행률이높았다는국외선행연구결과와도유사하다 [9]. 사전의사결정에대한태도를설명하는변수를확인하기위해서단계적회귀분석을한결과가족기능, 지각된건강상태, 학력, 연령이유의한요인으로확인되었다. 첫째, 가족기능은회귀모형에서가장유의한요인이었다 (β=.39, p <.001). 이는사전의사결정에가족기능이중요한요인으로작용한다는 Matsui[20] 와 Carr, Moorman과 Boerne[27], Kim[15] 의연구결과와일치한다. 그러나 Kim[15] 의연구에서는가족기능이좋지않은경우사전의사결정을더선호하는것으로나타났으나, Carr, Moorman 과 Boerne[27] 의연구에서는가족관계가좋지않은경우사전의사결정이행률이낮았다. 본연구에서노인암환자는가족기능이좋은경우자신이결정한 456 Korean Journal of Adult Nursing
노인암환자의사전의사결정에대한태도와관련요인 것을가족이따라주리라믿으며, 대상자의 62.3% 가가족과꼭상의하여결정하고자하여노인암환자의사전의사결정에 가족 이중요한요인으로작용하는것을알수있다. 이는흑인과유럽인에비해서한국인은가족과상의하여의사결정하기를원한다는연구결과와일치하고 [26], 조화로운가족기능에가치를두고가족과함께결정하는것을중시하는우리나라의사회문화적특성이반영된결과이다 [28]. 그러므로앞으로사전의사결정제도를구축함에있어이러한우리나라의문화적특성을고려하여생의말치료계획에대한접근방법과논의체계를수립해야할것이다. 둘째, 스스로건강상태를높게평가할수록사전의사결정에대한태도가더긍정적이었다. 이는건강을부정적으로지각할수록사전의사결정이행률이더높다는선행연구결과와일치하지않지만 [12], 자가보고한건강상태가좋을수록사전의사결정에대한태도가긍정적이었다는다른연구결과와는일치한다 [15]. 이러한결과는질병수준이심각하지않을경우, 동등한의사결정을하고자하나건강이악화되면결과에대한책임이두려워의사결정참여도가낮아진다는선행연구를토대로해석할수있다 [29]. 그러므로질병초기에의료진이예후나치료과정에대해서설명하고, 적절한시기에사전의사결정에대한정보를제공하여반복적인대화를하는것이대상자의두려움을감소시킬수있을것이다. 셋째, 고학력일수록사전의사결정에대한태도가긍정적이었는데 (p <.001), 이는선행연구결과와일치하며 [30] 고학력일수록사전의사결정과관련된정보를의미를잘이해하며, 의료진및가족과상의하는것을선호하기때문인것으로사료된다. 본연구대상자는대졸이상이가장많았던반면, Lee 와 Park[21] 의연구에서복지관이용노인은초등학교졸업학력이가장많았고대졸이상은 7.8% 에불과했다. 이와같은대상자의학력차이로인해 Lee와 Park[21] 의연구보다본연구에서사전의사결정에대한태도가더긍정적으로나타난것으로보인다. 학력의차이는 Lee와 Park[21] 의연구에비해남성의비율이많아일반적으로남성이여성보다학력이높기때문이거나, 본연구가자료를수집한의료기관이용환자의사회, 경제적특성이반영된결과로해석할수도있다. 넷째, 고연령일수록사전의사결정에대한태도가부정적이었다. 이는국외선행연구와차이가있으나 [30], 젊을수록사전의료지시에찬성하는비율이높아진다는 Pyun[4] 의연구결과와는유사하다. 이는국내외의문화적차이에기인한결과일수있다. 우리나라노인의경우, 자신의의사나자율성에가치를두고이를중시하는분위기가형성된지오래되지않았다. 그리고 80세이상고령노인은배우자가사망한후대부분자녀에게부양을받아의사결정도자녀에게의존하는경향이있어위의결과는이러한우리나라사회적특성에비추어그이유를생각해볼수있겠다. 본연구의제한점은대상자의대부분이간담췌계통암환자라는것이다. 이는의료기관의특성이반영된결과이며, 자료수집중에진료과와의협의등의부수적인제약으로인해다른암환자를대상자로할수없었기때문이다. 그러므로연구의결과를전체노인암환자에게일반화하는데제한이있다. 또한자료조사전연구대상자의 30.0% 가사전의사결정제도에대해서알고있었으며, 모르는대상자에게는사전의사결정에대한구조화된간단한정보를제공하고설문조사를진행하였다. 대부분의대상자가연명치료에대해서는의견을가지고있지만사전의사결정이라는제도를모르는경우이어서간단한정보제공으로그의미를쉽게이해하였다. 그러나설문조사전간단한정보제공으로짧은시간동안에충분히고민을한후설문조사에임했다고보기힘들기때문에제한이있다. 결론및제언본연구는노인암환자의사전의사결정에대한태도를파악하고, 이에영향을미치는요인을확인하고자하였다. 연구결과가족기능, 지각된건강상태, 학력, 연령의 4개변수에의한회귀모형이유의한것으로나타났다. 사전의사결정에대한태도에가장큰영향을미치는요인은가족기능이었다. 노인암환자와의료진간의논의가부족하므로의료진에의한교육과논의가활성화되어야하며, 중요한요인인가족을포함한의사결정을고려해야한다. 이를위해서는보건의료정책및제도적장치가뒷받침되어야할것이며, 무엇보다도생의말치료에대한의사결정은노인의자율성을최대한보호하고, 임종과정의고통을최소화할수있도록노인암환자스스로독립적의사결정을할수있는환경을조성해야한다. 이상의연구결과를토대로다음의제언을하고자한다. 첫째, 본연구는의사결정능력에문제가없는노인을대상으로하였는데치매환자등의의사결정능력에문제가있는대상자의연명치료중단을위해고려해야할요인과의사결정을지원할수있는방안에대한후속연구가필요하다. 둘째, 본연구는대학병원노인암환자를대상으로한연구로노인암환자전체에게일반화하기엔어려움이있다. 그러므로다양한환경에있는노인암환자를대상으로한후속연구가필요하다. Vol. 27. 4, 2015 457
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