Earticle

본 연구는 노인환자의 사전의료의향서에 대한 태도를 결정하는데 영향을 주는 요인을 파악하기 위해 충남 소재 요양병원 5곳과 종합병원 1곳에 입원한 65세 이상의 노인 환자를 대상으로 조화된 설문지를 이용하여 조사하였 다. 사전의료의향서에 대한 태도는 2.84점으로 평균이상 수준, 가족기능은 2.73점으로 평균 이하의 수준이었으며, 자 기효능감은 3.45점으로 평균 이상의 수준이었다. 연구 결과, 가족기능이 좋을수록 사전의료의향서에 대한 태도가 부 정적(r=.-.324, p<.01)이었으며, 자기효능감이 좋을수록 사전의료의향서에 대한 태도가 긍정적인 것으로 나타났다 (r=.340, p<.01). 본 연구는 사전의료의향서가 국내에 정착하는데 기여할 것이다.

This study was conducted to understand influential factors in determining the advance directive attitudes of elderly patients. Structured survey questionnaires were distributed using a convenience sampling method to the residents of long-term-care facilities. As a result, the attitudes toward advance directives were accounted having 2.84 points, the functions of a family with 2.73 points, and the level of self-efficacy with 3.45 points. Participants who have higher family functions were found to have negative attitudes toward self-efficacy, as the relationship between two variables were in the negative correlation (r =-.324, p<.01). However, participants who have higher self-efficacy showed positive attitudes toward advanced directives as the two variables were in the positive correlation (r =.340, p<.01). This study will contribute to the settlement of the AD in Korea.

Lately, heated discussions have developed in the medical and academic circles as to whether patients' self-decision to cease their own life-sustaining care could be justified in light of respect toward death with dignity. What served as a decisive momentum for such discussions was the ethical and medical view of care for the terminally ill, followed by vehement debates in full scale from the medico-legal standpoint. The criminal law has maintained its firm stand against withdrawal of meaningless life-sustaining care from the view of so-called "the principle of absolute protection of human life". There have on the one hand been angles arguing that such perspective of the criminal law does not coincide with the reality but does only add extra burden on the part of patients' families and even medical staff as well, worsening their legal stability and possible anticipation in their living. On the other hand, there have been positions claiming that it would be too early to introduce withdrawal of meaningless life-sustaining care like shock therapy in theoretic as well as real terms. Lots of debates have already been well under way about the death with dignity along with the issue of euthanasia in Korea but have not met any positive approaches toward its solution. In this midst, the Supreme Court of Korea provided recently a criterion for death with dignity on the occasion of its first decree allowing such death. This measure is widely accepted as a representative example of 'judicial activism' with which the court ventured to stop gap between incomplete legislation and real situation by means of positive interpretation of laws in consideration of social pressure to see the death with dignity allowed whereas the National Assembly and the Administration have been overtly conscious of the public opinion. However, under the circumstances in which there is no legal support to determine the death with dignity in legal terms, there may still exist limitation in solving legal disputes to follow in the future by making use of this decree as the only legal basis. Since the court is essentially expected to interpret and apply the laws, it must be beyond its capacity to decide the issue of death with dignity since it requires of the court the sense of judgement equivalent almost to legislation.

Purpose: The purpose of this study was to describe nursing students' perception of well-dying and knowledge for Advanced Directives. Methods: Nursing students from one university were selected for the research and a survey was carried out during March and April, 2019. A total of 133 nursing students participated in this study. Data were analyzed using t-test, ANOVA, $x^2$ test with SPSS statistics 21.0. Results: According to the results, the mean score for perception of well dying was $3.00{\pm}0.31$, and knowledge for Advance Directives was $9.05{\pm}2.20$. Perception of well-dying was significantly different by grade group. Knowledge for Advance Directives was significantly different by pre-education experience. Conclusion: In order to improve the nursing students' knowledge for advanced directives, it is necessary to develop education program and provide them through the total school years.

Purpose: This study was conducted to explore the perception and preference toward death with dignity, hospice palliative care, and advanced directives of the public. Methods: In July 2010, 121 citizen who visited a hospice promotional booth in the firework festival, was participated the survey. And 103 questionnaires were analysed for the study results. Results: Less than 60% of participants understood the purpose of hospice palliative care correctly but 76% of them said that they intended to choose hospice palliative care for themselves. The most preferable place of death was home (41.2%), and the most important conditions for the dying with dignity were 'to be without burdening others' (19.3%), and 'being with family and/or loved ones' (18.8%). Most of them agreed the necessity of advanced directives. Conclusion: This study shows that there is possibility of consensus on hospice palliative care and advanced directives, and public in Korean culture values being with family without burdening their family for dying with dignity.

A survey was conducted among medical professionals including hospices, nurses, and administrative personnel who often heard the concept of AD and had many chances to observe related medical occasions to grasp their attitudes toward the preparation of AD. The logistic regression analysis was conducted to examine whether the objects agreed upon preparation of the form of AD and its effect on decisions about meaningless life-prolonging treatment. Factors affecting decisions about the preparation of AD included religion and education in the case of hospices, income and education in the case of nurses, and marriage, income, working experience, legislative institutionalization, and education in the case of administrative personnel. Factors affecting the decision of rejecting meaningless life-prolonging treatment (life-prolonging equipment) included working experience and the one who would make out the form in the case of hospices, income, and working experience in the case of nurses, and income and working experience in the case of administrative personnels. Factors affecting the decision of rejecting meaningless life-prolonging treatment (artificial nutrient supply) included working experience and the one who would make the form in the case of hospices, working experience in the case of nurses, and income and working experience in the case of administrative personnel. It turned out that there was a difference in the recognition of AD and meaningless life-prolonging treatment among medical professionals. Hence, it is vital to deliver accurate information on Advanced Directives, reduce differences among the members, and form a social consensus so that patients' right of autonomous choice and dignity can be guaranteed.

본 연구는 혈액투석환자의 사전연명의료의향서(Advance directives, 이하 AD) 작성 의향에 영향을 미치는 요인을 파악하고자 시도되었다. 본 연구는 C시 소재 2개 종합병원에서 외래 및 입원을 통해 혈액투석을 받고 있는 환자 165명을 대상으로 하였으며, 자료수집은 2019년 7월 5일부터 2020년 4월 1일까지 설문지를 이용하여 진행하였다. AD 작성에 유의한 영향을 미치는 변인은 최종학력, AD에 대한 지식, AD에 대한 태도였다. AD 작성 의향이 있는 그룹에서는 고졸(3.62배, 95%CI: 1.57~8.33)과 대졸 이상(3.35배, 95%CI: 1.23~9.10)의 비율이 중졸 이하에 비해 상대적으로 높았다. AD에 대한 지식은 21점 만점 중 점수가 1점 상승할수록 AD 작성 의향이 1.12배(95%CI: 1.01~1.24) 증가하였다. AD에 대한 태도는 5점 만점 중 점수가 1점 상승할수록 AD 작성 의향이 1.13배(95%CI: 1.004~1.27) 증가하였다. 대상자 중 임종기에 ‘투석치료를 지속하겠다’는 군이 ‘투석치료를 지속하지 않겠다’는 군보다 AD 작성 의향이 낮았다. 하지만 AD 작성 의향이 있는 그룹 중 임종기 혈액투석치료를 지속하겠다는 사람의 비율도 18.5%를 차지하였다. 혈액투석환자들이 AD에 대한 올바른 지식과 태도를 갖고 생애말기 치료에 대한 자신의 가치와 신념을 확인할 수 있도록 환자, 가족 및 의료진 간 지속적인 논의를 할 필요가 있다.

The purpose of this study was to identify the factors that influence Hemodialysis patients’ in-tentions to write Advanced Directives (ADs). A questionnaire was used to collect data from 165 chronic renal failure patients receiving hemodialysis treatment at two general hospitals in South Korea. The variables that were found to have a significant influence on the intention to write an AD were education level, knowledge of Ads, and attitudes toward ADs. Patients with a university degree or high school education were significantly more likely (3.35 times and 3.62 times, respec-tively) to write an AD than were those without a high school education. In terms of knowledge of ADs, as the score increased by 1 point out of 21, the intention to write an AD increased by 1.12 times. Regarding attitudes toward ADs, as the score increased by 1 point, the intention to write an AD increased by 1.13 times. Patients that would choose to continue dialysis treatment during the end-of-life period were less willing to write an AD than those who would stop the dialysis treatment. However, 18.5% of those willing to write an AD indicated that they would continue hemodialysis treatment during the end-of-life period. The results of this study suggest that discus-sions between patients, family members, and healthcare providers are required from the beginning of dialysis treatment so that these patients have the right knowledge and attitudes about ADs and can confirm their values and beliefs about end-of-life care.

과학의 발전과 새로운 의료기술의 발전으로 인해 이전에 치료법이 알려져 있지 않은 만성질환-즉 고혈압, 당뇨, 암 등을 지닌 환자에게 의학적인 치료가 가능하게 되어 삶의 질을 높이고 생명을연장하게 되었다. 의료진은 심각한 질환에 알맞은 치료를 제공해야 한다. 또한 의료진은 환자의 원하는 점을 파악하고 이에 알맞고 가장 환자에게 알맞은 의료적 돌봄을 제공해야 한다. 사전의료의향서는 말기환자에 대한 돌봄을 결정하는데 의학적 윤리뿐만 아니라 법적인 요구를 감안하고 있다. 의료진은 심폐소생술, 수혈, 인공호흡기와 경구 혹은 정주의 영양 공급과 같은 연명치료와 관련되어결정하기 위해서 환자와 그 가족들과의 대화기법과 지식을 충분하게 지녀야 한다. 또한 의료진은환자에게 시행되는 의료행위는 정부에서 정한 법의 테두리 안에서 환자의 돌봄의 계획에 대하여 책임을 져야 한다. 말기환자의 치료에 대하여 광범위한 법적인 동의가 있으나 아직 우리나라에서는사전의료의향서에 대한 법률이 제정되어 있지 않다. 말기 환자를 돌보는 의료진에게는 이러한 윤리적, 법적인 이해를 하는 것이 중요하며, 본인들이 시행한 의료행위는 법에 의해 보호받아야 한다. 그러므로 말기환자에 대한 사전의료의향서를 허용하기 위하여 법적인 뒷받침이 있어야 하며 구체적인 내용과 방식에 대한 합의가 정부와 전문가의 노력이 함께 필요할 것이다.

Because new science and technology have offered the potential of medical therapies previously unknown, people with chronic diseases, which are hypertension, diabetes mellitus, and cancer,have good living and prolong life. Physicians should provide comfort in the front of serious illness. Also, they are responsible for offering that the patient's wishes and are documented and supported by the appropriate medical orders. Advance directives (AD) is not only medical ethical but also legal requirement in end of life care decisions and may be in placed and helpful. It is critical that physicians have the knowledge and skills necessary for communication of decisions related to life-sustaining treatment including cardiopulmonary resuscitation, transfusion, artificial ventilator,and nutrient supply including intravenous or oral uptake. Also, they have a responsibility to make ethical decisions in the care of patients within the law that governs their medical practice. Although there is broad legal consensus on much of end of life treatment, there is not law for AD in Korea. It is important for physicians who take care for patients with terminal diseases to understanding the ethics and legal consensus. The effort of expert for terminal care and concerned AD and a governmental organization is necessary to make law to allow AD.

본 연구의 목적은 암환자의 연명의료 사전의사결정 태도를 확인하고, 이러한 태도의 심리ㆍ가족ㆍ사회적 영향 요인을 알아보는 것이다. 이를 위해 2021년 3~9월 경기도 소재 종합병원 내 만 19세 이상의 성인 암환자 182명에게 대면 설문조사를 진행 후, 위계적 회귀분석을 실시하였다. 그 결과, 가족기능이 연명의료 사전의사결정에 유의한 정적 관계(β=.280, p<.01)를 보임을 확인하였다. 주요 변수들의 하위 영역을 포함한 분석을 통해 죽음불안의 하위 영역 중 존재상실에 대한 불안이 낮을수록(β=-.332, p<.001), 사회적지지의 하위 영역 중 의료인의 지지가 높을수록(β=.179, p<.01), 가족기능의 하위 영역 중 가족 적응성이 높을수록(β=.347, p<.05) 대상자의 연명의료 사전의사결정 태도가 긍정적이었다. 이는 연명의료 사전의사결정 과정에 환자에게 주체성 부여를 통한 죽음불안 완화와 함께 의료인 및 전문가의 지지적 접근과 가족 역동성의 평가가 중요함을 시사하였다. 본 연구 결과는 국내 사망원인 1위인 암환자의 연명의료 사전의사결정과 사전연명의료의향서를 활성화하는 이론적 근거로 활용될 수 있을 것이다.

This study aimed to contribute to the dignified death of patients with cancer by investigating psychological, family, and social factors affecting patients’ advanced directives(AD). From March to September 2021, a face-to-face survey was conducted on 182 adult cancer patients aged 19 or older in a general hospital in Gyeonggi-do, and a hierarchical regression analysis was conducted. As a result, the family function showed a significantly positive correlation with AD(β=.280, p<.01). Through analysis including sub-areas of major variables, the lower the anxiety regarding loss of existence(β=-.332, p<.001) among the sub-areas of death anxiety, the higher the support of medical personnel(β=.179, p<.01) among the sub-areas of social support, and the higher the family adaptability(β=.347, p<.05) among the sub-areas of family function, the more positive the attitudes were toward AD. This suggested that the supportive approach of medical personnel and experts and the evaluation of family dynamics are important, along with mitigating death anxiety through the assignment of subjectivity to patients in the AD process. The results of this study can be used as a theoretical basis for activating AD for patients with the No. 1 cause of death in Korea.

‘환자의 자기결정’은 연명치료 중단을 인정하는 주된 취지이자 연명치료중단의 핵심적 요건이다. 연명의료의 중단 혹은 거부의 문제에 있어서는 절차의 정당성을 확보하는 것이 중요한데, 정당화의 근거는 환자의 자기결정권에 있기 때문이다. 환자의 자기결정이 무엇인가는 환자의 명시적 의사나 추정적 의사를 통해 확인될 수 있지만 임종이 가까운 말기 환자의 의식은 명료하지 못하고, 의식이 분명한 경우에도 연명의료에 대한 본인의 의사를 충분히 표현할 수 없는 경우가 많아, 사전의료지시서에 대한 필요성이 강조되고 있다. 우리나라에서는 아직 사전의료지시서에 대한 법규정이 없으나, 환자가 임종기에 이르러 그 의사를 표명할 수 없는 경우를 대비하여 미리 작성하는 사전의료지시서에 대한 입법적 해명이 필요하다. 프랑스의 레오네티법에서는 여명의 단축 혹은 연장과 직접 관련된 사안에서 임종기 환자의 자율성을 존중하는 것을 원칙으로 하고 있다. 특히 환자의 의식이 있는 경우와 없는 경우, 사전의료지시서(directives anticipées)를 준비한 경우와 그렇지 않은 경우를 나누어 환자의 여명을 단축할 수 있는 결정하는 절차를 규정하고 있다. 그러나 2005년 레오네티법 발효 이후에도 사전의료지시서가 일반에 널리 알려지지 않았으며, 그 효과 또한 미미하였기에 최근 발의된 개정안은 환자의 자율성 존중을 위해 사전의료지시서의 강제력과 대항성을 강화하는 한편 서식을 일원화하는 규정을 도입하였다. 본 논문에서는 아직 국내에 상세히 소개되지 않은 레오네티법의 내용에 대해 간략히 소개하고, 그중 사전의료지시서의 요건, 효력, 양식을 최근 프랑스 국회에 상정된 개정안과 관련하여 검토하였다.

In France, the policy debate on the suffering of the end of life was revived in the early 2000s at the event " Vincent Humbert ," after which the "assessment mission to the accompaniment of end of life" is created within the National Assembly under the chairmanship of deputy Jean Leonetti . It is carried on 22 April 2005, the enactment of a law, called " Leonetti law" on the Rights of the sick and dying.* Assistant professor, College of Law, Soongsil University French law till now excludes aggressive therapy but condemns the so-called active euthanasia. But The text aims to avoid euthanasia practices, and also prevent aggressive therapy (called an "unreasonable obstinacy" in the treatment of end of life patients). It thus allows the patient to request, within a defined framework, stopping too heavy medical treatment. This desire can be expressed in particular through advance directives or by using a trusted person. Since 2005 and the Leonetti law, anyone age and capacity to make known his wishes regarding end of life - including his refusal of any aggressive treatment in case she would one day be unable to express their will - is able to formulate advance directives. In the new text, driven again by Jean Leonetti and Alain Claeys, these guidelines may now be necessary to the doctor, "except in life-threatening emergencies during the time required for a full assessment of the situation" . They will also be unlimited validity but revisable and revocable at any time. Whereas they were previously written on paper, a formal model will see the light, to avoid the inaccuracies it more difficult for doctors. Their existence will additionally shown on the vital card. These legislative changes on advance directives are informatives and thought provoking.

본 연구는 간호대학생의 좋은 죽음에 대한 인식, 사전의료의향에 대한 지식과 태도의 관계를 확인하고, 사전의료의향서에 대한 태도의 영향 요인을 알아보고자 수행되었다. 3개 대학교 간호대학생 173명을 대상으로 구조화된 설문지를 통해 2018년 7월부터 9월까지 조사하였다. 수집된 자료는 SPSS 22.0프로그램을 이용하여 t-test 와 ANOVA, Scheffe test, Person’s correlation, multiple regression을 실시하였다. 연구결과로 첫째, 좋은 죽음 인식은 4점 만점에 2.88점, 사전의료의향서에 대한 지식은 9점 만점에 7.50점, 사전의료의향서에 대한 태도는 4점 만점에 2.83점으로 나타났다. 둘째, 간호대학생의 좋은 죽음에 대한 인식 및 사전의료의향서에 대한 지식은 사전의료의향서에 대한 태도와 유의한 정적인 상관관계가 있었다. 셋째, 간호대학생의 사전의료의향서에 대한 태도의 영향요인을 분석한 결과, 좋은 죽음에 대한 인식(β=0.435, p<.001) 사전의료의향서 작성의향(β=0.248, p<.001), 사전의료의향서 작성 시기(β=0.154, p=.014), 가족, 친지 임종경험(β=144, p=.026)이며, 설명력은 34.5 %로 나타났다. 결론적으로 간호대학생의 사전의료의향서에 대한 태도를 증진시키기 위한 다양한 요인을 파악하고, 좋은 죽음에 대한 교육 프로그램 개발이 요구된다.

The purpose of this study was to identify the factors influencing on nursing student’ attitudes toward Advanced Directives. Nursing students from 3 nursing college in D city were selected for the research and a survey was carried out from July to September, 2018. A total of 173 nursing students participated in this study. To data were analyzed by t-test, ANOVA, Scheffe test, Person’s correlation, multiple regression using SPSS statistics 22.0. According to the result, The mean score of perception of good death was 2.88, knowledge for advance directives was 7.50, attitudes for advance directives was 2.83. Attitudes toward advance directives was significant positive correlations between perception of good death and knowledge for advanced directives. The significant influencing factors on attitude toward advanced directives were perception of good death (β=0.435, p<.001), intention of documenting written advanced directives(β=0.248, p<.001), time of documenting written advanced directives(β=0.154, p=.014) and experience of death in the family members(β=144, p=.026) explaining 34.5% of the variance in the multiple regression analysis. Therefore, in order to improve the nursing students' attitude for advanced directives, it is necessary to understand factor influencing attitudes toward advanced directives and develop strategies and educational programs for nursing student about end-of-life-care.

본 연구의 목적은 사전의료의향서에 대한 의료관계자들의 인식과 태도를 파악하는데 있다. 부산광역시 소재 병원 급 의료기관 7개에 종사하고 있는 호스피스, 간호사, 행정직원을 대상으로 설문조사를 시행하였으며, 최종 665부(호스피스:208, 간호사:230, 행정직원:227)를 분석하였다. 조사기간은2014년01월04일부터 01월25일까지 22일간 이었다. 자료처리는 일반적 특성, 인식과 수용태도, 작성자와 작성 시기, 제도 및 대리인 지정에 대한 태도를 알아보고자 χ2-test, 사전의료의향서 작성 동의에영향을 미치는 요인을 알아보기 위하여 로지스틱 회귀분석을 하였다. 연구결과, 사전의료의향서 작성동의에 영향을 미치는 요인으로 호스피스의 경우는 사전의료의향서 인식유무, 간호사의 경우는 소득,출생지역, 행정직원의 경우는 소득, 출생지역, 근무(봉사)경력, 법률제정, 법정 대리인 지정 변수가 영향요인으로 분석되었다. 본인의 의사를 자신의 생명결정권에 최대한 반영할 수 있도록 체계적인 기준마련, 사전의료의향서에 대한 인식변화 그리고 제도의 법제화가 이루어져야 한다.

The purpose of this study is to investigate awareness on Medical personnel'sawareness and attitudes which affects to writing Advanced Medical Directives. Medical personnel(hospice volunteers, nurse, administrative personnel) from 11 hospital level in Busan were selected for the research and a survey was carried out for 47 daysfrom April 04, 2014 to February 17, 2014. The Medical personnel(hospice volunteers,nurse, administrative personnel) were asked to answer questions by themselves andanswers from a total of 665 Medical personnel(hospice volunteers: n=208, nurse:n=230, administrative personnel: n=227). To data were analyzed by factor analysis,crosstabs and logistic regression using SPSS statistics 21.0. According to the result, the hospice volunteers was influence on the writing Advanced Medical Directives of awareness writing Advanced Medical Directives. The nurse was influence on the include income, region of birth of awareness writing Advanced Medical Directives. The administrative personnel was influence on the include income, region of birth, career, legislation and representative of awareness writing Advanced Medical Directives. there is a need to understand that patients with incurable diseases have rights to die with dignity and to live on a life of a human being. and there is a need to awareness change to writing Advanced Medical Directives.