協助超長住院病人出院規劃的臨床困境：一例報告

Discharge Planning for a Patient with Prolonged Hospital Stay

本文係作者以護理長兼個案管理員角色，利用出院規劃的概念協助一位因腦下垂體腫瘤手術，住院574天病人的出院經驗。個案住院期間由於疾病與治療過程的複雜性，加上家庭問題及家屬對治療期望太高而滯院，醫師雖曾八度提出出院的要求家屬因照顧資源不足，以種種理由一再拖延。但經由出院規劃小組人員的協調及一致的態度，終使家屬接受出院。且在出院追蹤結果發現病人確實得到良好的後續照顧，顯示師能病人在病況穩定後出院回家是最好的安排。故出院規劃除了提升病人的自我照顧能力和家屬的照顧能力外，也節省醫療資源且增強家庭的凝聚力。而有效的出院規劃除了須醫院首長的支持，在整個醫院的人力資源上應給予跨科部的統合支配，並在政策作業流程上作必要的調整和配合外，醫療團隊成員各自發揮所長的情況下方能滿足病人的需求，更有助於出院規畫的推動。

This case study describes the role and function of a case manager in a discharge planning program. The case manager used the concept of discharge planning to help a post-operative pituitary tumor patient be discharged from the hospital to home. The patient's total hospital stay was 574 days. The causes of the prolonged stay were the complexity of the disease and the treatment process, conflicts among family members, and their unreasonably high expectations to the patient's recovery. Although the surgeon suggested that the patient be discharged on eight separate occasions, the family choose to delay or refuse discharge for a variety of reasons, including inability to care for the patient because of insufficient resources. With coordination of the discharge planning program by the case manager and the supportive attitudes of all the discharge planning team members, the family finally allowed the patient to be discharged from the hospital. In the follow-up telephone interview, it was found that the patient received proper care after discharge. The patient's self care ability and the family members' caring skills were improved by this program. Also, the medical resources were properly used and family cohesion was enhanced. In conclusion, a successful discharge planning program needs not only support from the department superiors to reorganize human resources and regularions, but also the professional participation of each team member.