長期照護機構推行安寧療護模式之成效探討—以台北市至善老人安養護中心為例

Measuring the Effectiveness of Hospice-care Model Provided in Long-Term Care Facilities：An example in Zhi-Shan Long-Term Care Facility

許馨文(Hsin-Wen Hsu)

指導教授 ： 陳雅美

國立臺灣大學/公共衛生學院/健康政策與管理研究所/碩士(2019年)

https://doi.org/10.6342/NTU201902978

摘要

研究背景：隨著人口老化及家庭結構的改變，入住長期照護機構的老人逐漸增加，機構也成為許多老人生命末期的照護地點，機構如何推行安寧療護也應獲得重視。在台灣安寧療護政策雖發展快速，但對於長照機構的安寧療護，目前除了針對機構中末期住民提供「安寧居家護理」或「社區安寧療護」，尚未見到具體的方向與做法。
研究目的：本研究以台北市至善老人安養護中心為個案，進行長期照護機構實施安寧療護之成效評估探討，並期望至善經驗能提供後續長照機構推行安寧療護之參考。
研究方法：本研究以「台北市至善老人安養護中心」為個案，以SWOT分析法制定長照機構推行安寧療護策略，並以Donabedian’s model為基礎制定長照機構安寧療護模式之成效評估架構，進行長照機構推行安寧療護之成效評估，針對結構面、過程面及結果面進行評估。在結構面，以末期照護組織、機構特性及人力資源作評估；在過程面，以人員之間的溝通及機構人員的照護技術作評估；在結果面，則分析「照護程序結果」中機構安寧療護介入前後住民「安寧緩和醫療暨維生醫療抉擇意願書」簽署率、死亡個案於機構在地臨終比率、末期住民於機構在地臨終比率、反覆出入院的頻率及住院天數的比較，並分析死亡個案接受安寧療護的比率及「家屬感受結果」。
研究結果：至善老人安養護中心為了推行安寧療護，經過結構面(如成立機構內安寧照護團隊、進行安寧教育訓練、設置獨立的臨終關懷室、建置末期照護標準作業流程、建立與社區醫院的轉介流程等)、過程面(如舉行安寧個案討論會以強化機構人員間的溝通整合、透過家庭會議及牧靈關懷活動強化與住民及家屬間的溝通、利用教育訓練及個案實務學習強化機構人員的照護技術)及結果面(如以「照護程序結果」及「家屬感受結果」作成效評估)的變革，克服最初SWOT分析中所面臨的劣勢(機構員工訓練及接受度不足、住民與家屬的接受度不足、末期住民在地臨終的困難)與威脅(機構安寧缺乏具體完整政策及專家指引故各機構作法不一而成效未知、擔心與社區醫院聯結有變)，至善安寧模式執行2年後在結果面的分析上發現能增加住民「安寧緩和醫療暨維生醫療抉擇意願書」簽署率及於機構在地臨終比率；而「安寧居家護理」或「社區安寧療護」服務在統計上呈現顯著減少末期住民反覆出入院的頻率及住院天數，並增加其於機構在地臨終的比率。但死亡住民接受安寧居家照護比率為30.6%，未達半數，需強化與住民討論預立醫療照護計劃能力並進一步評估是否增加其他末期住民篩檢方式。而在家屬感受分析結果中，可看到住民及家屬們對於至善安寧模式的感受皆是滿意的。
結論：至善經驗中發現，結構面的變革是機構推行安寧療護初期最基本且重要的，唯有完善結構面，才能促成良好的照護過程面，進而達到預期的結果面。在結構面中最重要的部分包括：需完備機構人員的照護能力，能建立機構內的安寧照護團隊更佳、設置臨終關懷室、重視靈性關懷及強化與社區醫院之間的聯結；在過程面，可利用個案討論會強化機構人員間的溝通整合、利用家庭會議及牧靈關懷活動促進機構人員與住民及家屬間的溝通及加強人員末期照護的技術；在結果面，可採用「臨床照護結果」(包括末期住民的住院頻率、住院天數、死亡地點、DNR簽署率、安寧療護轉介率等)及「家屬的感受結果」作評估，未來則可考慮增加「照護程序結果」(包括末期住民症狀控制程度、疼痛評估頻率、情緒障礙比率、人工營養的使用率、不必要的藥物使用率及被約束率等)及「機構員工的感受結果」。而可再精益求精的部分是強化人員與住民討論預立醫療照護計劃的能力及評估是否需增加其他末期住民篩檢方式，以成為更完善的機構安寧模式。

關鍵字

長期照護機構 ； 安寧療護 ； 安寧居家護理 ； 社區安寧療護 ； Donabedian’s架構 ； SWOT分析

並列摘要

Background: As the population ages, the number of elderly living in long-term care facilities has gradually increased. Most residents will remain in a long-term care facility until their deaths. Thus, promoting hospice care in long-term care facilities should be a priority. However, the hospice care policy in long-term care facilities has not yet seen a practical model in Taiwan other than providing Home/Community-Based Hospice Care for residents with terminal diseases in long-term care facilities.

Purpose: To evaluate the effectiveness of the Hospice-care Model in Zhi-Shan Long-Term Care Facility. We expect that the experience of hospice care in Zhi-Shan Long-Term Care Facility will provide a practical example for other long-term care facilities to implement hospice care in the future.

Methods: This study used a SWOT analysis to identify core strengths, weaknesses, opportunities, and threats of hospice care in Zhi-Shan Long-Term Care Facility and developed strategic plans for providing hospice care in Zhi-Shan Long-Term Care Facility based on the results of the SWOT analysis. Then we developed a model to measure the effectiveness of Hospice-care Model in Zhi-Shan Long-Term Care Facility. The model was based on the Donabedian’s model, and we assess the effectiveness through three perspectives: “structure,” “process,” and “outcome.” In our study, structural performance was measured by (1) the special team for end-of-life care, (2) facility’s characteristics, (3) facility’s resources and staffing. Process performance was measured by (1) status of communication and coordination among providers, (2) status of communication with residents and families, (3) assessment of end-of-life symptoms, (4) delivery of appropriate medications or treatments. Outcome performance was measured by (1) comparing the signing rate of Do Not Resuscitate(DNR) directives among all residents before and after providing hospice care in the facility, (2) comparing the percentage of in-facility deaths before and after providing hospice care in the facility, (3) comparing the number and days of hospitalization among residents with terminal diseases 3 months before and after receiving Home/Community-Based Hospice Care, (4) the percentage of in-facility deaths among residents with terminal diseases received Home/Community-Based Hospice Care ,(5) the percentage of the dead who ever received Home/Community-Based Hospice Care, (6) family perceptions of hospice care.

Results: After implementing the structure, process and outcome reform since the end of 2015, Zhi-Shan Long-Term Care Facility has overcome the weaknesses (lack of training and acceptance of the staff, lack of acceptance of the residents and families, and difficulties in dying in the facility for the residents) and threats (lack of definite policies and expert guidelines of hospice care in facilities, and worry about changes of the support from the community hospital) of the SWOT analysis initially. Structure reform consisted of setting up a hospice-care team in the facility, staff education in hospice care, setting up a private room for dying residents and their families, publishing end-of-life care protocols for residents with terminal diseases, and creating referral protocols with the community hospitals. Process reform consisted of holding terminal-case meetings to promote communication and coordination among providers, holding family meetings and spiritual care activities to promote communication with residents and families, and strengthening staff’s end-of-life care skills through education and case practice. Outcome reform consisted using processes of care outcomes and family perceptions of care to measure the effectiveness of hospice care. The results showed that the provision of hospice care in Zhi-Shan Long-Term Care Facility has increased the singing rate of DNR and increased the percentage of in-facility deaths among residents. A pre-post comparison also showed that after providing Home/Community-Based Hospice Care to residents with terminal diseases, the number and length of hospitalizations significantly decreased. And the family members were satisfied with the hospice-care services in Zhi-Shan Long-Term Care Facility. However, the proportion of the dead who ever received Home/Community-Based Hospice Care was not more than half.

Conclusion: According to the results of the study, the hospice care model in Zhi-Shan Long-Term Care Facility can be considered a successful experience. The structural change is the most basic and important in the early stage of implementing hospice care in long-term care facilities. Only by perfecting structure domains can improve process domains, and then achieve the expected outcome domains. This experience illustrates the most important projects on structural reform included (1) improving the hospice care skills of staff, setting up hospice teams within the facility is better,(2) offering a private room for dying residents and their families, (3) arranging spiritual care, (4) linking to the community hospitals. The process reform included (1) holding terminal-case meetings to promote communication and coordination among providers, (2) holding family meetings and spiritual care activities to promote communication with residents and families, (3) strengthening staff’s end-of-life care skills through education and case practice. The outcome reform included using processes of care outcomes (e.g., DNR orders, site of death, proportion of residents with hospice care prior to death, hospitalizations) and family perceptions of care to measure the effectiveness of hospice care. Furthermore, residents’ clinical care outcomes (e.g., pain and other symptoms management, spiritual and emotional distress, receiving intravenous or tube feedings, physical restraints) and staff’s perceptions are recommended to be included as measures for assessing the effectiveness of hospice care. In order to become a competent hospice-care model, Zhi-Shan Long-Term Care Facility shall further educate staff in documenting advance care plans for residents on admission and find a better screening tool to identify terminal patients in the future.

並列關鍵字

long-term care facilities ； hospice care ； home-based hospice care ； community-based hospice care ； Donabedian’s framework ； SWOT analysis

參考文獻

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