安寧緩和醫療的知識、態度和臨床技能的探討

Knowledge, Attitude and Clinical Skill of Family Physicians Toward the Hospice Palliative Care

姚建安(Chien-An Yao) ； 邱泰源(Tai-Yuan Chiu) ； 胡文郁(Wen-Yu Hu) ； 陳慶餘(Ching-Yu Chen)

《安寧療護雜誌》 10卷2期 (2005/05) Pp. 139-145

https://doi.org/10.6537/TJHPC.2005.10(2).4

摘要

改善末期病人的照顧的迫切需求目前已經成為許多末期照顧的中心論述，然而末期病人的症狀控制往往不理想，心理症狀包括焦慮、憂鬱等仍是主要的問題，與病人和家屬溝通治療選項與安寧療護往往不夠，許多大型的研究指出要改變末期照顧的型態，需要根本轉移醫師對末期照顧的態度，所以許多對醫師的末期照顧教育訓練也正在進行。美國家庭醫學研究會在1998年出版了家庭醫學科住院醫師末期照顧建議的核心教育指引，詳細陳述住院醫師在訓練完畢前應具備的末期照顧的態度，知識和技能。因為醫師參與病人的照顧能得到最好的學習效果，所以最新的教學活動應該給予更多的時間在照顧病人的床邊教學，因此導致目前醫學教育聯合委員會致力於認定醫師末期照顧勝任能力的重要性，需要所有美國和加拿大的醫學院校課程包含末期照顧。有證據顯示緩和醫療教育能夠改變末期照顧的態度，因此也支持醫院醫師末期照顧教育的需求。安寧療護和專科緩和醫療服務的國家會議對於在急性住院病房醫師有關末期照顧教育的建議，提出如下七要項：症狀控制、溝通技能、使用末期照顧的技術、醫學倫理、病患和家屬的需求與價值觀、其他照顧場所，和法律議題。至於阻礙末期照顧教育包括不適當的態度，缺乏末期照顧的知識，不良的執業行為，和快速變化的醫療照顧經濟系統。醫院仍是照顧許多瀕死病人的重要場所，同時也是訓練醫師接受末期照顧的知識，態度和臨床技能的基地，所以改善教學的傳統，教師的培育，和醫院支持的氛圍都需要來達到有意義的改善。

關鍵字

緩和醫療 ； 安寧療護 ； 末期照顧 ； 知識 ； 態度 ； 技能 ； 醫師

並列摘要

The urgent need to improve the care of dying patients has been the central message of many recent reviews of the current state of end-of-life care. The empirical research among diverse populations has suggested that the symptom control at the end of life is often inadequate. Psychological symptoms including anxiety and depression continue to be a major problem. Communication among patients, families and physicians about preferences for care and alternative treatment options, including hospice, is infrequent. Several commentators has suggested that changing care at the end of life will require fundamental shifts in the attitudes towards terminal illness among physicians. Currently, several educational programs designed to modify physicians' attitudes towards end-of-life care are underway. In 1998, American Academy of Family Practice published ”Recommended Core Education Guidelines for Family Practice Residents in End-of-Life Care” and illustrated the residents' competences about attitudes, knowledge and skills towards the end-of-life care. Since physicians learn best by participating in the care of patients, new educational innovation must dedicate time to teach physicians in the clinical arena where that care is delivered. A consequence of the work to date led the Liaison Committee for Medical Education to recognize the importance of physician competence in end-of-life care with a requirement that all accredited U.S. and Canadian medical schools include end-of-life care in their curricula. Evidence that palliative care education can change attitudes to terminal care supports the need for such education particularly among hospital doctors. In 1997, National Council for Hospice and Specialist Palliative Care Services suggested seven educational domains for end-of-life care applicable in the acute care hospital setting, including symptom control, communication skills, use of technology in end-of-life care, ethics, needs and values of the patient and family, other care settings, and legal issues. Barriers to improving education about end-of-life care in the acute care setting include inappropriate attitudes, lack of knowledge, poor practice behavior, and the rapidly changing system of health care economics. The acute care hospital will continue to be an important locus of care for many dying patients. Significant changes in educational culture, faculty development, and the supporting hospital environment are needed to effect meaningful improvements.

並列關鍵字

palliative care ； hospice ； end-of-life care ； knowledge ； attitude ； skill ； physician