推展「預立醫療照護諮商（ACP）」參與促進失智症個案接受安寧療護的機會

Promoting Advance Care Planning to Give Patients with Dementia the Opportunity to Receive Hospice Palliative Care in their End of Life

張丞淯(Cheng-Yu Chang) ； 陳怡如(I-Ju Chen) ； 黃淑鶴(Shu-He Huang)

《安寧療護雜誌》 25卷2期 (2021/03) Pp. 124-142

https://doi.org/10.6537/TJHPC.202103_25(2).03

摘要

失智症個案自主理解與決策能力喪失的時間，比其生命末期的時間點提早甚多，醫療照護決策常倚賴家屬決定，以致病人本人的自主意願無法充分表達並落實。2013年台灣接受安寧療護的失智者僅占總人數的1.64％，健保資料庫研究指出，台灣失智病人生命最後一年有很高比例接受過無效醫療，包括高達七成接受過管灌餵食、六成曾接受氣管內管插管及呼吸器治療，三成曾執行心肺復甦術急救，近兩成仍在洗腎。本文針對病人家屬、醫護人員及政策面分別探討失智症個案安寧療護利用上其可能障礙因素，發現病人及家屬對於安寧療護不瞭解、錯誤認知及態度影響之下，或是醫療人員的教育訓練、溝通技巧或是醫療體制規範等都是影響失智症個案能否在疾病早期接受預立醫療照護諮商（ACP）與擬定預立醫療決定（AD）的因素。這些障礙將會影響失智症末期個案在疾病末期接受安寧療護的機會。本文透過與癌症病人的比較，闡述失智症個案更迫切在仍有自主決策表達能力的罹病初期就先接受「預立醫療照護諮商」以利簽署「預立醫療決定」，讓失智症個案的最後一哩路，能依據個案的期望度過，以提升失智症個案接受安寧療護的機會。

關鍵字

預立醫療照護諮商 ； 預立醫療決定 ； 失智症 ； 無效醫療 ； 安寧療護

並列摘要

Patients with dementia lose their ability to understand and make decisions much earlier than their end of life. Their medical care decisions are often made by family members; thus, the patient's own will is not autonomously expressed and implemented. In 2013, only 1.64% of all patients with dementia in Taiwan received hospice palliative care (HPC). Data from the National Health Insurance Database indicates that high percentages of patients with dementia in Taiwan have received futile medical care in the last year of their life; for example, up to 70% of patients have received tube feeding, 60% have received endotracheal intubation and mechanical ventilation, 30% have received cardiopulmonary resuscitation, and approximately 20% have underwent hemodialysis. This article discusses the possible obstacles to the use of HPC for patients with dementia with regards to family members, medical staff, and policies. Both patients and family members are discovered to be affected by ignorance, misunderstanding, and an inadequate attitude toward HPC. A lack of education and training and poor communication skills of medical staff as well as medical system procedures are all factors affecting the ability of patients with dementia to receive advance care planning (ACP) and sign an advance decision (AD) in the early stage of the disease. These barriers affect the likelihood that patients with dementia will receive HPC at their end of life. Compared with cancer patients, patients with dementia are more eager to receive ACP in the early stage of the disease when they have the ability to make decisions, express themselves autonomously, and sign an AD. This AD will enable patients in the last stage of dementia to live and be cared according to their will, thus increasing the likelihood that they will receive HPC.

並列關鍵字

advance care planning ； advance decision ； dementia ； futile medical care ； hospice palliative care

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