從醫院到社區，末期病人照護模式中社會工作師角色的反思－以臺大醫院金山分院為例

本文藉由社工師自身觀察，另輔以個案紀錄彙整，針對現行照護模式進行認識與理解，藉以探討社工師在醫療團隊和病人及家庭中所扮演的角色。呈現金山分院社區安寧社工師參與團隊醫療工作之狀況，整理與省思社工師在其中的角色與功能。從在地老化到在家終老，從醫院照顧到社區照顧，建立五全的照顧，特別是全社區的呈現，在其中社工師是醫療團隊中不可或缺的一員，雖然實際服務中也遇到很多限制及挑戰，但參與在團隊中並不是孤軍奮戰，因為在院長「堅叔」的帶領下的金山末期病人照護團隊雖然在人力、資源及時間上不是最理想，但卻持續的紮實的在社區中照護需要的病人及家屬，一個個「足感心」的服務不斷上演中，而且會繼續下去。

關鍵字

末期病人；社工師角色

並列摘要

The purpose of this paper is to understand the role of social worker among the medical team, patients and their families, the hospital social workers used self-observations and case records to analyze the care service model of the NTUH Jin-Shan Branch Hospital. The paper presents how the social workers participated in the community palliative service team. To sort out and reflect on the roles and functions of social worker The social worker is essential to the medical team, especially when the services are focused on establishing five full care, caring in the community and dying at home. Although there are lots of limitations and challenges in practical work, the social workers are not alone in the team due to the team leader, Huang Shen-gjian, M.D. It is solid and sustained in the community care for patient and their families in need. A ＂full sense of the heart＂ service is appearing on the stages and will continue.