末期腎病病人之安寧緩和療護與預立醫療照護諮商

台灣末期腎病的發生率及盛行率皆高居全球之冠，症狀負荷嚴重、生活品質低下，加上平均餘命有限及高死亡率，突顯末期腎病病人接受安寧緩和療護之高度需求，台灣健保署正式亦將非癌八大末期疾病之一：末期腎病，納入安寧緩和療護健保給付範圍。本文係針對末期腎病之流行病學、醫療給付、病情變化軌跡、症狀負荷與生活品質，闡述臨床實務如何執行及強化「以末期腎病病人為中心」的預立醫療照護諮商，在醫療團隊與病人和／或家屬的有效溝通下，有計畫地為末期腎病病人訂定醫療照護目標，尊重病人的治療意願與選擇，以執行適切醫療照護措施。此外，綜合論述醫療人員藉由安寧緩和療護的知能，落實腎病末期病人之疼痛／症狀處理、預立醫療照護諮商、病人／家屬的心理、社會與靈性支持、不予／撤除透析醫療決策的倫理議題，以及影響簽署書面之預立醫療指示之相關因素，冀能有效地提升腎病病人的末期醫療照護品質，以達生死兩無憾！

關鍵字

末期腎病；安寧緩和療護；預立醫療照護諮商；透析；決策

並列摘要

According to Taiwan ranks top in incidence and prevalence rate of end-stage renal diseases. As end-stage of renal diseases take a heavy toll on the patient lowering the quality of life and shortening the lifespan, the importance of the care for patients with end-stage renal disease becomes ever more evident. Taiwan's National Health Insurance Administration began payment of hospice and palliative care for end-stage patients of eight non-cancer diseases, of which end-stage renal disease is one. Renal palliative care includes pain and symptom management, advance care planning (ACP), psychological welfare of the patients and their families, societal and spiritual support, and the ethical question of dialysis. ACP respects the wishes and decisions of the patients. After having affectively communicated with the patients and/or family members, the medical team will plan out goals for medical care and execute appropriate care to ensure the quality of life at the end stages of the patient. This paper gives a comprehensive discussion of the epidemiology of ESRD and medical payments, disease trajectory, survival rate, symptom burden and quality of life, renal palliative care and the clinical application of ACP for ESRD. This paper hopes to reinforce medical professionals' knowledge of the ACP and AD to effectively raise ESRD patients' quality of life.

並列關鍵字

ESRD ； hospice palliative care ； advance care planning ； hemodialysis ； decision

參考文獻

Wong, S. P., Kreuter, W., & O’Hare, A. M. (2012). Treatment intensity at the end of life in older adults receiving long-term dialysis. Arch Intern Med, 172, 661-662. doi:10.1001/archinternmed.2012.26

陳瑞娥、林秋菊（2016）．慢性腎臟病患預立醫療自主計畫模擬情境溝通訓練方案之建構．護理雜誌，63（3），105-111。