體制內的善終?
老年醫學科與安寧緩和醫療團隊之跨專業合作模式之初探研究

一般醫院的老年醫學科倡導全人醫療和整合性專業團隊合作，期望能滿足高齡患者在生理、心理、社會，以及靈性等各層面需求。同時，也因老年醫學科的患者嚴重老化和罹患多重疾病的生理問題，比起一般人更早面臨死亡和和維護善終的議題，具有接受安寧療護服務的迫切性。過去「安寧療護」主要以末期病人為服務對象，2009年起健保局將「八大非癌末期疾病」納入安寧療護給付範圍的規定，似乎開啟老年醫學科患者也能接受安寧療護服務的契機，然實際上目前老年醫學科的高齡患者能獲得安寧療護服務的人數仍有限。究竟「八大非癌末期疾病」規定如何制訂、老年醫學科患者無法獲得安寧療護的原因為何，以及如何突破老年醫學科與安寧緩和醫療團隊合作模式的限制，使高齡患者獲得合適的靈性照顧，是本研究主要研究重點。本研究採深度訪談法，針對南部地區某醫學中心的老年醫學科與安寧緩和醫療團隊之醫師、安寧共照護理師、社工、老年醫學科個管師、護理長、護理人員，共11位，進行資料收集，以瞭解老年醫學科和安寧緩和醫療等團隊成員對於目前跨專業合作模式的經驗、限制，以及未來的修正建議。主要研究結果包括：1.專業人員對安寧照護之於高齡患者的看法為：心理與靈性層面的照顧來得比生理治療重要、能協助回顧生命，賦予正向意義，以及能減少無效醫療，提升臨終的生活品質；2.老年醫學科患者使用安寧療護服務的障礙主要分為兩大類，一是制度因素：包含八大非癌收案標準嚴格、醫院管理和資源配置影響安寧緩和醫療服務之供給、以治療為主的醫學觀點：安寧緩和醫療認知的不足、現有照會機制的缺陷與問題；二是家庭因素：避談死亡的家庭文化；3.老年醫學和安寧療護團隊未來合作契機需建立在具高層支持、強化醫療資訊系統，以及提升出院準備服務功能等基礎上。本研究提出具體建議如下：1.健保局應重新檢視「住院安寧緩和醫療」以及「安寧居家療護」的範圍及收案標準；2.強化醫護人員對安寧緩和醫療之概念與認同；3.跨專業團隊合作的契機與可能性；4.建置有效率的資訊回覆系統；5.破除避談死亡的文化

關鍵字

安寧緩和醫療；老年醫學；老年疾病；靈性；臨終關懷

並列摘要

In general hospitals, the Department of Geriatrics and Gerontology advocates holistic medicine and integrated collaboration of multidisciplinary teams, hoping that this kind of integrated care can meet the physical, psychological, social and spiritual needs of the elderly patients. At the same time, just because of the severe aging problem of the patients of the Department of Geriatrics and Gerontology and their big physical problem of multiple diseases, these patients face the issues of death and protection of peaceful dying earlier than any other patients, and have greater imminence to receive hospice and palliative care services. In the past “hospice care” mainly takes terminally ill patients as the service targets. From 2009 National Health Insurance Administration included “8 major non-cancer terminal diseases” in the Regulations for Benefit Package of Hospice Care Payment. It seemed that patients of the Department of Geriatrics and Gerontology could also receive hospice and palliative care services. Nevertheless, in fact the number of the elderly and terminally ill patients of the Department of Geriatrics and Gerontology currently permitted to receive hospice and palliative care services is still very limited. Then, how were the regulations for those “8 major non-cancer terminal diseases” formulated? Why couldn’t patients of the Department of Geriatrics and Gerontology receive hospice and palliative care? And how can we break through the limitations for collaborative model of the Department of Geriatrics and Gerontology and the Hospice and Palliative Care Team so as to let the elderly patients acquire proper spiritual care? These questions are the main research issues of the study. The study employed in-depth interview method, collecting information from 11 interviewees who were doctors, co-caring hospice nurses, social workers, case management officers of the Department of Geriatrics and Gerontology, the head nurse and nurses working at the Department of Geriatrics and Gerontology as well as the Hospice and Palliative Care Team of an academic medical center in Southern Taiwan. With the collected information, the study attempts to know about the experience and limitations of the staff of the Department of Geriatrics and Gerontology as well as the Hospice and Palliative Care Team towards the existing transdisciplinary collaborative model, and also their suggestions for future revision. The main research results of the study are: 1. Regarding the hospice care for the elderly patients, the professional staff think that psychological and spiritual care for them is more important than physical treatment. What the professional staff can do for the elderly patients are to help them have a look back at their lives, give life positive meaning, decrease ineffective medical treatment, and improve the quality of life before death. 2. The obstacles for patients of the Department of Geriatrics and Gerontology to acquire hospice care services are mainly divided into two parts. The first part is the factor of system, which contains strict standard in case acceptance of 8 major non-cancer terminal diseases, effects of hospital management and resource distribution on the supply of hospice and palliative care services, treatment-based medical viewpoints, insufficient cognition of hospice and palliative care, and defects and problems of the existing care mechanism. The second part is family factor, which refers to the traditional culture that family members avoid talking about death. 3. The future collaboration opportunities for the Department of Geriatrics and Gerontology and the Hospice and Palliative Care Team are established on the foundation of supports from high-rank government departments, strengthening of medical information system, and improvement of preparatory service function before discharge of elderly patients from hospital. The study gives some concrete suggestions as follows: 1. National Health Insurance Administration should review the scope and case acceptance standard of “hospital-based hospice and palliative care” and “home-based hospice care.” 2. The medical care staff’s concepts and recognition of hospice and palliative care should be strengthened. 3. Opportunities and probability for collaboration of transdisciplinary teams should be increased. 4. Efficient information reply system should be established. 5. The culture that avoids discussion of death should be eliminated.