長期照顧機構安寧療護服務模式之研究

The Study of Hospice and Palliative Care in Long-term Care Institutions

李依臻(I-Jhen Lee)

指導教授 ： 黃源協

國立暨南國際大學/人文學院/社會政策與社會工作學系/博士(2017年)

摘要

本研究透過長期照顧機構住民需求與工作者立場，呈現對長照機構推行安寧療護服務之適切性與看法，並企圖建構安寧療護照護模式，以供相關單位、機構與實務專業人員參考。依地理區域於全國舉辦六場焦點團體會議與深度訪談，分別訪談工作者65位與住民15位。
機構住民因慢性疾病或老化衰退死亡歷程軌跡呈「器官衰竭」或「慢性衰退」軌跡，入住機構宜開始宣導安寧理念，讓住民適時與適切的接受良好之生命末期照護方式。各長期照顧機構所具備之醫療照護、人力配置與資源連結能力各不相同，本身即存有結構因素的差異，也因為結構因素的差異自然發展成適合各機構之安寧型態。機構實行安寧療護時面臨著困境與限制，機構負責人、工作人員、住民、家屬與社區居民，各自不同的立場與價值觀阻礙安寧施行，機構本身的結構面與安寧緩和理念無法接軌，以及醫療體系與機構雙方都因為避免醫療糾紛而未給住民適宜處置。
若要解決所面臨困境，機構須提升相關人員之安寧療護教育認知，並對家屬與住民進行教育與宣導，建立機構的安寧核心團隊成員、制定機構安寧收案制度及服務流程，並解決機構死診開立問題、促進DNR同意書的通用性，設立安寧療護或臨終關懷之住民獨立空間。建議政策促進機構實施安寧療護，提供機構負責人實施之誘因，實務面向則應以合作醫院為後盾、建立有效運作團隊，由機構內整頓適當實體設備與空間，建立雙向運作流程與制度，以確認外在資源連結、良善溝通與全人照護之落實，構成安寧療護之各單位的橫向聯繫，提供安寧住民連續性照護。

關鍵字

長期照護機構 ； 安寧療護 ； 照護模式

並列摘要

This study investigated the opinions of residents and workers in long-term care (LTC) institutions concerning the provision of customized hospice and palliative care services in the institutions to establish a hospice and palliative care model that has policy and practical implications. Six focus-group meetings were conducted with 65 LTC institution workers and in-depth interviews with 15 LTC institution residents across Taiwan.
With their residents suffering from organ dysfunction or chronic degeneration induced by chronic illnesses or age-related degeneration, LTC institutions should promote hospice and palliative care in a manner that ensures timely and proper end-of-life care. However, these institutions differ in their approach to administering hospice and palliative care because of differences in the capability to administer medical care, allocate manpower, and link resources. Furthermore, the implementation of such care service in LTC institutions entails several limitations. These include (1) disagreements among the institutions’ directors, workers, and residents, the relatives of the residents, and locals; (2) the failure of the institutions to bring their internal structural characteristics in line with their perceptions about hospice and palliative care; and (3) lack of proper medical treatment for the residents due to the reluctance of the institutions and health facilities to become involved in medical disputes.
To address these limitations, LTC institutions can equip their caregiving personnel with further knowledge about hospice and palliative care, disseminate information about the care service to their residents and the relatives thereof, organize a core team tasked with the care service, develop a system and procedure for derlivering the care service, resolving difficulties issuing death certificates, improve the universality of do-not-resuscitate (DNR) orders, and provide independent spaces for residents under hospice and palliative care or end-of-life care. LTC policies should be formulated in a manner that will facilitate hospice and palliative care implementation in institutional settings. To ensure consistent hospice and palliative care, LTC institutions should liaise closely with hospitals, provide facilities and spaces tailored to their residents, and develop shared processes and systems for hospice and palliative care administration, thereby connecting with external resources, coordinating effectively with their stakeholders, delivering holistic care, and communicating laterally with organizations involved in hospice and palliative care.

並列關鍵字

long-term care institution ； hospice and palliative care ； care model

參考文獻

李存白、楊婉伶、蘇逸玲（2009）。護理人員在安寧療護照護之角色與使命。護理雜誌，56（1），29-34。

林慧美、楊嘉玲、陳美妙、邱泰源、胡文郁（2011）。住院病人簽署預立醫療指示的意願及接受宣導的意向。安寧療護雜誌，16（3），281-295。

黃源協（2007）。長期照顧管理中心的團隊運作。長期照護雜誌，11（1），20-26。

趙可式（2009）。台灣安寧療護的發展與前瞻。護理雜誌，56（1），5-10。

一、中文部分