임종기 환자 의료 결정에 대한 의사의 태도: 완화적 진정을 중심으로
The Attitude of Doctors towards End-of-Life Care Decision-Makings in Korea: Focused on Palliative Sedation
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초록
완화적 진정은 말기 환자가 임종할 때까지 지속적인 깊은 진정을 유도하는 의료행위로, 임종을 앞당기려는 의도 없이, 다른 방법으로는 조절이 불가능한 여러 증상을 경감시키려는 목적으로 시행되는 완화의료적 접근이며, 안락사나 의사조력자살과는 분명하게 구분되는 의료 행위이다. 그러나 그 경계의 모호함으로 인하여 직접적인 시행에는 지속적으로 논란이 있다. 이에 본 연구에서는 완화적 진정을 중심으로 임종기 의료 결정에 대한 의사의 태도를 파악하고 이를 토대로 진료지침 및 관련 교육과정 개발을 위한 기초자료를 제시하고자 한다. 이를 위해 전국 5개 병원의 전문의 88명을 대상으로2013년 5월 및 9월에 직접적 지면기입방식의 설문조사를 시행하였다(응답율 95.5%). 설문지는 기존의 임종기 의료 결정에 관한 인식 조사 연구에서 사용된 것으로 크게 능동적 적극적 안락사, 의사조력자살, 연명의료의 유보 및 중단, 그리고 완화적 진정에 대한 내용으로 구성되었다. 그 결과 연명의료유보(73.8%), 완화적 진정(47.6%), 연명의료중단(20.2%), 능동적 적극적 안락사(8.3%), 의사조력자살(4.7%)의 순으로 찬성하였으며, ‘모르겠다’라고 응답한 비율은 완화적 진정(27.3%), 연명의료중단(20.2%), 의사조력자살(15.4%), 능동적 적극적 안락사(10.7%), 연명의료유보(9.5%) 순으로 나타나완화적 진정에 대한 전반적인 인식 정도가 낮음을 알 수 있다. 이에 완화적 진정과 능동적 적극적 안락사나 의사조력자살과의 구분 등 임종기 의료 결정에 있어서의 진료지침의 개발과 이에 대한 졸업 후의학교육의 시행이 시급히 이루어져야 하며, 이에는 단순하게 한 순간의 의료 행위 여부 만을 결정하는 것이 아니라 환자 및 보호자, 사회문화적 환경을 고려한 연속적인 의사소통 과정으로 이해되어야만한다는 점도 반영되어야 할 것이다.
Abstract
Palliative sedation (PS) is used to deal with refractory symptoms in terminally ill patients when all other palliative approaches have failed. While it is not performed with the intention of hastening death, it remains one of the most contentious medical practices in the context of palliative medicine. This study aims to investigate the perception of doctors towards PS and other types of end-of-life care, and to provide insight for developing medical guidelines for PS. A survey involving a written questionnaire was conducted on doctors in five hospitals in South Korea. The questionnaire contained five statements concerning medical decisions about types of end-of-life care, including PS. Doctors were asked whether they agreed or disagreed with each statement. A total of 84 questionnaires were analyzed, with a response rate of 93.2%. The percentages of agreement with the given statements on PS, voluntary active euthanasia (VAE), physician assisted suicide (PAS), withholding life-sustaining treatment, and withdrawing life-sustaining treatment are 47.6%, 8.3%, 4.7%, 73.8% and 20.2%. The majority of the doctors surveyed in this study do not support PS for terminally ill patients in severe pain. The results of this study suggest that appropriate medical guidelines and post graduate medical ethics education on the end-of-life decisions should be provided for doctors in Korea.
참고문헌 (44)
- Calvo Espinos C, "Palliative sedation for existential suffering in primary care: A thin red line", Atencion primaria (2015)
- van Delden JJ, "Terminal sedation: source of a restless ethical debate", Journal of Medical ethics, 33(4), pp.187~188 (2007)
- Juth N, "Moral differences in deep continuous palliative sedation and euthana sia", BMJ Supportive & Palliative care, 3(2), pp.203~206 (2013)
- Ridley S, "Uncertainty in end-of-life care", Current Opinion in Critical Care, 19(6), pp.642~647 (2013)
- Lossignol D, "End-of-life sedation: is there an alternative?", Current Opinion in Oncology, 27(4), pp.358~364 (2015)
- 김두식, "말기 진정", 한국호스피스완화의료학회지, 13(3), pp.139~142 (2010), 한국호스피스완화의료학회
- Anquinet L, "Physicians’ experiences and perspectives regarding the use of continuous sedation until death for cancer patients in the context of psychological and existential suffering at the end of life", Psycho-oncology, 23(5), pp.539~546 (2014)
- Maltoni M, "Palliative sedation for intolerable suffering", Current Opinion in Oncology, 26(4), pp.389~394 (2014)
- Van den Block L, "Euthanasia and other end-of-life decisions: a mortality follow-back study in Belgium", BMC Public Health, 9, pp.79~ (2009)
- Calvo-Espinos C, "Palliative sedation for cancer patients included in a home care program: a retrospective study", Palliative & Supportive Care, 13(3), pp.619~624 (2015)
- Gu X, "Palliative sedation for terminally ill cancer patients in a tertiary cancer center in Shanghai, China", BMC Palliative Care, 14, pp.5~ (2015)
- Azoulay D, "Palliative Sedation at the End of Life:Patterns of Use in an Israeli Hospice", The American Journal of Hospice & Palliative Care (2015)
- Strand JJ, "Palliative Sedation and What Constitutes Active Dying: A Case of Severe Progressive Dystonia and Intractable Pain", The American Journal of Hospice & Palliative Care (2014)
- Dumont S, "The use of palliative sedation: A comparison of attitudes of French-speaking physicians from Quebec and Switzerland", Palliative &Supportive Care, 13(4), pp.839~847 (2015)
- Schildmann E, "Palliative sedation therapy: a systematic literature review and critical appraisal of available guidance on indication and decision making", Journal of Palliative Medicine, 17(5), pp.601~611 (2014)
- Papavasiliou EE, "Current debates on end-of-life sedation: an international expert elicitation study", Supportive Care in Cancer : Official Journal of the Multinational Association of Supportive Care in Cancer, 22(8), pp.2141~2149 (2014)
- Rietjens JA, "Terminal sedation and euthanasia: a comparison of clinical practices", Archives of Internal Medicine, 166(7), pp.749~753 (2006)
- Anquinet L, "Similarities and differences between continuous sedation until death and euthanasia - professional caregivers’attitudes and experiences: a focus group study", Palliative Medicine, 27(6), pp.553~561 (2013)
- Sercu M, "Belgian general practitioners'perspectives on the use of palliative sedation in end-of-life home care: a qualitative study", Journal of pain and symptom management, 47(6), pp.1054~1063 (2014)
- Swart SJ, "Considerations of physicians about the depth of palliative sedation at the end of life", CMAJ : Canadian Medical Association Journal = Journal de l’Association Medicale Canadienne, 184(7), pp.E360~E366 (2012)
- Foley RA, "Attitudes Regarding Palliative Sedation and Death Hastening Among Swiss Physicians:A Contextually Sensitive Approach", Death studies (2015)
- Gurschick L, "Palliative Sedation: An Analysis of International Guidelines and Position Statements", The American Journal of Hospice & Palliative care (2014)
- 오승민, "일개 의과대학생의 말기 환자 치료 결정에 대한 태도", 한국호스피스완화의료학회지, 11(3), pp.140~146 (2008), 한국호스피스완화의료학회
- 김정아, "교수개발로서의 생명의료윤리 교육: 신임교원 대상 교육개발과 시행 경험을 바탕으로", 생명윤리정책연구, 8(2), pp.1~22 (2014), 생명의료법연구소
- 김상현, "무의미한 연명치료 중단에 대한 중환자 전담의사의 인식: 포커스그룹 인터뷰를 중심으로", 한국의료윤리학회지, 15(3), pp.370~384 (2012), 한국의료윤리학회
- 김순자, "종합병원 간호사의 Do-Not Resuscitation 경험에 따른 연명치료중단 지식과 태도", 한국의료윤리학회지, 15(3), pp.355~369 (2012), 한국의료윤리학회
- 이은영, "삶의 마감 시기 의사결정의 윤리적 이슈 - 의사결정 모델 제안을 중심으로", 한국의료윤리학회지, 15(2), pp.160~183 (2012), 한국의료윤리학회
- 김현경, "말기환자 돌봄 교육 후 의과대학생의 인식과 태도 변화", 한국호스피스완화의료학회지, 15(1), pp.30~35 (2012), 한국호스피스완화의료학회
- 문재영, "중환자의 윤리적 쟁점들", 한국의료윤리학회지, 18(1), pp.1~9 (2015), 한국의료윤리학회
- 권복규, "우리나라 일부 병원에서 환자, 보호자, 의료진의 연명치료 중지 관련 의사결정에 관한 태도", 한국의료윤리학회지, 13(1), pp.1~16 (2010), 한국의료윤리학회
- Putman MS, "Intentional sedation to unconsciousness at the end of life: findings from a national physician survey", Journal of Pain and Symptom Management, 46(3), pp.326~334 (2013)
- Koper I, "Consultation with specialist palliative care services in palliative sedation: considerations of Dutch physicians", Supportive care in cancer : official journal of the Multinational Association of Supportive Care in Cancer, 22(1), pp.225~231 (2014)
- Curlin FA, "To die, to sleep: US physicians’religious and other objections to physicianassisted suicide, terminal sedation, and withdrawal of life support", The American Journal of Hospice & Palliative Care, 25(2), pp.112~120 (2008)
- LiPuma SH, "Expanding the Use of Continuous Sedation Until Death: Moving Beyond the Last Resort for the Terminally Ill", The Journal of Clinical Ethics, 26(2), pp.121~131 (2015)
- Trankle SA, "Decisions that hasten death:double effect and the experiences of physicians in Australia", BMC Medical Ethics, 15, pp.26~ (2014)
- Swart SJ, "Continuous palliative sedation: not only a response to physical suffering", Journal of Palliative Medicine, 17(1), pp.27~36 (2014)
- Anquinet L, "Descriptions by general practitioners and nurses of their collaboration in continuous sedation until death at home: in-depth qualitative interviews in three European countries", Journal of Pain and Symptom Management, 49(1), pp.98~109 (2015)
- Raus K, "Continuous sedation until death:the everyday moral reasoning of physicians, nurses and family caregivers in the UK, The Netherlands and Belgium", BMC Medical Ethics, 15, pp.14~ (2014)
- Hernandez-Marrero P, "Ethical Decisions in Palliative Care:Interprofessional Relations as a Burnout Protective Factor? Results From a Mixed-Methods Multicenter Study in Portugal", The American Journal of Hospice & Palliative care (2015)
- Guevara-Lopez U, "New frontiers in the future of palliative care: real-world bioethical dilemmas and axiology of clinical practice", BMC Medical Ethics, 16, pp.11~ (2015)
- Spineli VM, "The process of palliative sedation as viewed by physicians and nurses working in palliative care in Brazil", Palliative & Supportive Care, pp.1~7 (2014)
- Nakazawa K, "Palliative Care Physicians’ Practices and Attitudes Regarding Advance Care Planning in Palliative Care Units in Japan: A Nationwide Survey", The American Journal of Hospice &Palliative Care (2013)
- Foo WT, "Factors considered in end-of-life care decision making by health care professionals", The American Journal of Hospice & Palliative Care, 30(4), pp.354~358 (2013)
- Bruinsma S, "Palliative sedation: a focus group study on the experiences of relatives", Journal of Palliative Medicine, 16(4), pp.349~355 (2013)