高齡者之預立醫療指示

Advance Directives in Older Adults

林綉君(Hsiu-Chun Lin) ； 李佳苓(Chia-Ling Lee) ； 張家銘(Chia-Ming Chang)

《台灣老年醫學暨老年學雜誌》 11卷2期 (2016/05) Pp. 89-104

https://doi.org/10.29461/TGG.201605_11(2).0002

摘要

醫療預立指示係指「個人意識清楚且具有決策行為能力時，為自己未來可能失去決定能力的情況，預先規劃個人所期望獲得的末期醫療處置與照護，並將此意願作一個預先的書面陳述、指示與說明文件」，使其於生命末期接受到適合自己心意的照護。2000年6月台灣立法通過「安寧緩和醫療條例」，主旨是讓重症末期的病人可以有選擇安寧療護，不接受積極治療的權利，以維護自身的善終權。2015年12月三讀通過《病人自主權利法》，希望賦予具備完全行為能力的成年人，可經專業醫療團隊的充份諮詢後，書面立下拒絕維生治療與其後接受緩和照護的指示，當其進入特定醫療臨床情境時，便得以接受緩和醫療的身心照護，尊嚴離世。然而許多文獻指出，預立醫療指示都是在非常迫近死亡時才決定，且多數民眾仍對於預立醫療指示內容不甚了解，而醫療體系推行末期醫療照護計畫的落實度不佳，導致病人很少有機會參與自身的醫療照護決策。相較於癌症患者，高齡者之共病症較多且複雜、拖延時間較久、生理機能衰退易受影響、易功能衰退而致長期臥床、易出現併發症或後遺症，且較易因檢查或治療出現不良反應。本文主要參考國內外文獻，概括討論預立醫療指示的概念、預立醫療指示與老年人相關的研究與推行的限制及建議，期能在臨床上增加醫療人員對醫療預立指示相關議題的了解，並提供更適切的照護。

關鍵字

advance directives ； advance care planning

並列摘要

An advance directive is defined as a mechanism of legal documentation by which individuals make known what medical treatment they want when they can no longer make the decisions for themselves. In June 2000, ＂Hospice-Palliative Care Act＂ was legally promulgated and implemented in Taiwan with the main purpose of allowing patients with terminal illnesses to choose hospice care. In December 2015, the promulgation of ＂The Patient Autonomy Act＂ further granted adults with full competency the right to document, after understanding the professional opinions from medical specialists in a comprehensive manner, an advance directive stipulating their decisions regarding life-sustaining treatment or hospice care in the event that they become unable to communicate their wishes. As indicated in the literature, the timing of determining DNR is usually near death, yet most people remain in need of being better informed about DNR and advance directive. The medical community has not faithfully implemented advance directives in the care of terminal illnesses, and the result is that patients are seldom involved in advance care planning. Compared to patients with malignant neoplasms, elderly patients with chronic diseases usually suffer from multiple comorbid conditions, longer duration of diseases, physiological vulnerability, functional decline, as well as complications, sequelae or adverse reactions to treatment. The paper strives accordingly to discuss the concepts, studies, limitations and recommendations related to the implementation of advance directives so as to help medical professionals provide more appropriate care in clinical practice with a better understanding of the issues involved.

並列關鍵字

advance directives ； advance care planning ； the aged