啟動生命末期議題－從社區整合照顧論之

Initiation of the Issues of End of Life Care in Community Integrated Care

翁瑞萱(Ruey-Shiuan Ueng) ； 陳麗如(Li-Ju Chen) ； 曾湘玲(Hsiang-Lin Tseng) ； 周姚均(Yao-Chun Chou) ； 楊美如(Mei-Ju Yang) ； 施至遠(Chih-Yuan Shih) ； 徐愫萱(Su-Hsuan Hsu) ； 李易翰(Yi-Han Lee) ； 孫文榮(Wen-Jung Sun) ； 白裕銘(Yu-Ming Pai) ； 陳靜琳(Ching-Lin Chen) ； 劉志光(Chih-Kuang Liu) ； 黃勝堅(Sheng-Jean Huang)

《北市醫學雜誌》 15卷2期 (2018/06) Pp. 1-8

https://doi.org/10.6200/TCMJ.201806_15(2).0001

摘要

我國非癌症總死亡人數中接受安寧療護照顧率僅佔2.11%，而當前長照資源分散且重疊、缺乏無縫隙之持續性及整體性照顧，社區中多重疾病失能者，是否能及早辨識生命末期個案或啟動討論是很重要的課題。本院為社區醫院期許達「社區醫療的領航者」願景邁進，於2016年始社區整合照顧 服務計畫，於市區三個里服務約1萬5千人，以居家醫療為主軸，個管師為單一窗口，至個案家中依個案之個別性需求，擬定照顧計畫並結合社政、衞政、民政及民間單位資源。服務102位病人中，非癌佔94%且三項以上慢性疾病佔5成以上，在服務首次評估即啟動生命末期議題佔9成，並進行跨專業溝通及轉銜照顧。高價值的社區整合照顧，應該由醫療團隊首次收案時，主動與病人家屬討論生命末期議題照顧計畫，促進醫病及跨專業間溝通和轉銜，進而帶動鄰里社區間之死亡識能，共創社區安寧療護之照顧體系。

關鍵字

生命末期 ； 安寧緩和諮詢 ； 社區整合照顧

並列摘要

Only 2.11% of patients in Taiwan who died of non-cancer diseases received palliative care and current long-term resources are scattered and overlapping, and lack of continuity and integrity care. As there are many people with multiple diseases in the community, it is essential to early identify the end of life subjects and initiate the discussion. Our hospital is a community hospital that promises to achieve the vision of leadership of community medicine. In 2016, we initiated a community-integrated care service program which served approximately 15,000 people in three urban areas. The single window were managed by case managers focusing on home care medicine, and they constructed the care plan according to individual needs of the cases, with the resource supports from the social, health and civil administrations and private sectors. Among the 102 patients being cared, 94% were of non-cancer diseases and more than half of the patients had three or more chronic diseases. We initiated the end of life issue for 90% of the cases at the first assessments and conducted cross-professional communication and transfer of care. High-value community integration care should include active discussion of end of life caring planning with patient's family from the beginning of case recruitments to promote shared decision and cross disciplines communications and push forward the death literacy in the communities, and to create a community palliative care system together.

並列關鍵字

end-of-life care ； palliative consultation ； community integration care