社區末期醫療體系的建立：以雲林為例

Establishing End-of-Life Care Program in the Community: Yun-Lin Experience

安寧療護「五全照顧」的內涵包括：全人、全家、全隊、全程、全社區。然而在台灣，不論診斷別，多數末期病人的生命末期都在醫院度過，鮮少能夠回到社區接受照顧。因此發展社區末期照護體系，至為重要。細究末期病人返回社區接受照顧的困境，可能來自醫療團隊、病人、家屬之間的溝通不足，而社區的醫護人員也尚未準備好。如果要讓末期病人返回社區接受照顧，提供居家療護至為關鍵。參照英國經驗以及文獻回顧，建立本土化社區末期照護體系的原則包括：（1）.從社區醫院做起，建立有效運作的團隊；（2）.與社區合作，並連結到社區資源；（3）.病情告知與持續溝通；（4）.提供居家訪視服務；（5）.盡可能尋找資源並支持照顧者，緩解照顧者負擔；（6）.長期照護機構應納入服務範圍；（7）.第一線護理人員必須具備及早發現末期病人的能力。本文簡介台大醫院雲林分院依此所建立的社區末期照護架構及評估工具，並期待未來能在政策的支持之下，促進倫理化社區末期醫療體系的建立。

Hospice palliative care provides holistic care for terminally ill patients. In Taiwan, however, most of these patients were cared in hospital during their last days of life despite their wish to be cared at home. Hence, it is important to establish end-of-life care programs in different communities. The barriers come from poor communication between patient, family, and healthcare team, and neither community physicians nor nurses are well prepared for caring terminal ill patients. Palliative home care is an effective solution. The principles of establishing end-of-life care program in the community embrace: (1). Developing palliative care team and care program by community hospital; (2). Forming a partnership between hospital and community; (3). Enhancing truth-telling and communication; (4). Providing home visits; (5). Searching for resources and relieving caregiver burden; (6). Taking account of long-term care system; (7). Developing nurses’ ability to identify terminal ill patients. The community end-of-life care program setup by National Taiwan University Hospital Yun-Lin Branch is introduced in this article, hence maybe facilitating in the establishment of an ethical community end-of-life care model in Taiwan.