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生命末期社區照護之團隊

生命末期社區照護之團隊. 台大醫院雲林分院 社區及家庭醫學部 彭仁奎 醫師. Comparison of Increasing Aged Proportion in Various Countries. Future Trend of Aged Populations in Taiwan. 97 年台灣死因統計. 惡性腫瘤 27.3% 心臟疾病 11.1% 腦血管疾病 7.5% 肺炎 6.1% 糖尿病 5.6% 事故傷害 5% 慢性下呼吸道疾病 3.8% 慢性肝病及肝硬化 3.5%

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生命末期社區照護之團隊

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  1. 生命末期社區照護之團隊 台大醫院雲林分院 社區及家庭醫學部 彭仁奎 醫師

  2. Comparison of Increasing Aged Proportion in Various Countries

  3. Future Trend of Aged Populations in Taiwan

  4. 97年台灣死因統計 • 惡性腫瘤 27.3% • 心臟疾病 11.1% • 腦血管疾病 7.5% • 肺炎 6.1% • 糖尿病 5.6% • 事故傷害 5% • 慢性下呼吸道疾病 3.8% • 慢性肝病及肝硬化 3.5% • 自殺 2.9% • 腎炎、腎徵候群及腎性病變 2.8% • 敗血症 2.5% • 高血壓性疾病 2.5% • 衰老/老邁 1.1%

  5. 生命末期的功能衰退 猝死 癌症 器官衰竭 虛弱老人 JAMA 2003;289:2387-92

  6. 安寧緩和醫療的定義 • WHO definition (1990) • The active total care of those patients whose disease is not responsive to curative therapy. • Control of pain, and of other symptoms, and of psychological and spiritual problems, is paramount. • The goal of palliative care is achievement of the best quality of life for the patients and their families. • Many aspects of palliative care are also applicable earlier in the course of the illness in conjunction with anticancer treatment.

  7. 安寧緩和醫療的定義 • WHO definition (2002) • An approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable treatment of pain and other problems, physical, psychological and spiritual.

  8. 安寧緩和醫療的定義 • 對象：末期病患任何可能進展至死亡的疾病患者，及其家屬 • 積極治療，以緩解（甚至預防）身體、心理、社會、靈性的苦痛（suffering） • 目標：提升病人與家屬的生活品質 • 及早介入，幫助更大

  9. 面對生命末期（無論診斷別）的病患，我們在社區照護方面是否已經做好準備？面對生命末期（無論診斷別）的病患，我們在社區照護方面是否已經做好準備？ • 能不能建構有效的團隊與運作模式，來幫助生命末期病患在社區中得到好的照護？

  10. 社區的醫師、護士準備好了嗎？ • Chiu et al: Establishment and evaluation of a scheme for facilitating community physicians to provide palliative care in Taiwan. 2007. • Hu et al: Nurses’ willingness to provide palliative care. J Pain Sympt Manage. 2003.

  11. MDS Full Report for the year (2005-2006)National Council for Palliative Care (NCPC)

  12. NHS End of Life Care Program (2004–2007) • Gold Standards Framework (GSF) • Liverpool Care Pathway for the Dying Patient (LCP) • Preferred Priorities for Care (PPC)

  13. NHS End of Life Care Program (2004-2007)

  14. Three triggers for Supportive/ Palliative Care • The surprise question • “Would you be surprised if this patient were to die in the next 6-12 months?” • Choice/ Need • The patient with advanced disease makes a choice for comfort care only, not ‘curative’ treatment, or is in special need of supportive / palliative care. • Clinical indicators

  15. The End of Life Care Pathway

  16. Step 1: discussions as end of life approaches • Open, honest communication • Identifying triggers for discussion

  17. Step 2: assessment, care planning and review • Agreed care plan and regular review of needs and preferences • Assessing needs of carers

  18. Step 3: coordination of care • Strategic coordination • Coordination of individual patient care • Rapid response services

  19. Step 4: delivery of high quality services • High quality care provision in all settings • Hospitals, community, care homes, hospices, community hospitals, prisons, secure hospitals, and hostels • Ambulance services

  20. Step 5: care in the last days of life • Identification of the dying phase • Review of needs and preferences for place of death • Support for both patient and carer • Recognition of wishes regarding resuscitation and organ donation

  21. Step 6: care after death • Recognition that end of life care does not stop at the point of death • Timely verification and certification of death or referral to coroner • Care and support of carer and family, including emotional and practical bereavement support

  22. 雲林地區老人及末期社區照護模組 • 從社區醫院做起 • 從社區、長照機構與急性病房等不同管道，經由醫療人員的評估篩選，找出末期老人個案（不限癌症），轉介至專業醫療團隊照護，擬定相關醫療計畫，結合社區相關醫療資源，提供完善的臨終末期照顧，以建立末期老人連續性照護示範模式。

  23. 狹義的生命末期照護之團隊：院內安寧團隊 • 醫師 • 護理師 • 社工師 • 病服員 • 心理師 • 宗教師 • 志工 • 藝術治療師 • 各專業領域共同協助

  24. 廣義的生命末期照護之團隊：結合社區的資源 • 家屬/照顧者 • 基層醫師（如：社區醫療群） • 長照機構的醫療相關人員 • 社區組織 • 民間社團

  25. 篩選 評估者向原單位 Comment 緩和醫療門診 社區 (家中) 評估 照顧目標 疾病治療/控制/照護 功能復健 症狀緩解 照顧者支持/資源整合 特殊照護需求 篩選 長照機構 緩和醫療門診 評估 篩選 急性醫療 (醫院) 緩和醫療會診 評估 符合安寧緩和醫療 收治標準？ 一般居家 一般病房收治 團隊持續追蹤 否 篩選工具： 安寧緩合照會需求評估表 訪視評估工具： Palliative Outcome Scale (POS)、 Zarit Caregiver Burden Scale. 是 安寧居家療護 安寧病房住院 安寧共同照護

  26. 照護內容 • 合理的病情判斷與生命期推估 • 預立醫療計畫 (Advance CarePlanning) • 團隊合作，提供全人照顧 • 症狀控制、功能復健 • 心理與靈性介入 • 提升生活品質 • 支持照顧者並提供資源 • 做好死亡教育與準備

  27. 安寧居家療護規範 • 申報本章各項費用之醫事服務機構需向本局提出申請經同意後始可申報，該機構需設有安寧居家療護小組（小組內須包括安寧療護專責醫師、社工師及專任護理師等至少乙名），小組成員皆需受過安寧療護教育訓練80小時（含）以上，繼續教育時數醫師、護理人員及社工人員為每年20 小時，成員更改時亦須通知健保局轄區各分局。

  28. 安寧居家療護收案要件 • 病患或家屬同意接受安寧療護，並簽署選擇安寧緩和醫療意願書或同意書。 • 末期疾病診斷 (10大項)。 • 經醫師診斷或轉介之末期狀態病患，其病情不需住院治療，但仍需安寧居家療護者。 • 病人之自我照顧能力及活動狀況需符合ECOG scale (Eastern Cooperative Oncology Group Scale) 2級以上 (對照 Patient Staging Scales，PS，Karnofsky： 50-60)。

  29. 一般居家 vs 安寧居家

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