為何回家是條漫漫長路？談思覺失調症病人出院的自主權

The Long Road Home: A Discussion of the Autonomy of Schizophrenia Patients after Their Discharge from the Hospital

能行使自主是尊重人權的展現，而自主的行使是個體的權利。思覺失調症病人病情穩定後有出院的權利，需尊重病人行使出院的自主，但也要顧慮家屬後續的照顧負荷，使病人出院回家成為一複雜的困境。本文以倫理的辯證，探討精神病人行使出院自主權的立論，期能提供臨床決策。決定能力是行使自主的必要條件，但病人的決定能力會隨事項而異，因此決定能力的評估無明確的切分點，而是在程度上的差別，故採用浮動評量的策略來衡量決策風險。當醫療風險越大，相對地病人的決定能力也要越高，才能確保病人的最佳利益。決定出院對精神病人而言是高風險的決策，若未能準備銜接出院的後續照護，反而不能保護病人。對於出院決策的執行，宜採協議決策的方式，醫療團隊在其中扮演溝通協調的角色，尊重病人的自主權與顧及家屬的照顧負荷，從病人住院即進行出院準備服務，建立出院後續照護系統與正向支持網絡，讓病人在回家這條路上能做好準備，繼而增進生活適應與促進疾病復元。

Every adult has the right to self-determination and to have his or her autonomy respected. While schizophrenia patients have the right to be discharged from the hospital, their needs subject their caregivers to high care loadings. This situation presents a dilemma for the medical team. The authors justify the patient's autonomy to request and to be granted a discharge. Then, present the decision-making process related to discharge for the reference of medical teams. Capacity is necessary to autonomy. There is currently no standard for assessing the capacity of patients that clearly defines their competence. A sliding scale approach to decision making distinguishes between decisions involving significant potential risk and, therefore, involving higher level of capacity requirements and decisions on minimal potential risk. In order to protect the interests of patients, the sliding scale approach takes into account different decisions. Cases in which schizophrenia patients choose to self-discharge involve a high-level of risk. Poor preparations for follow-up care lead to poor-quality patient care and may cause harm to the patients. In a share decision model, the medical team plays the role of negotiator between the patient and the family and respects the autonomy of the patient while supporting the family through the hospital discharge process. Medical team must have a discharge planning for the patient and family, follow-up care system, and support network. During hospitalization, the discharge plan aims to facilitate the life adaptation and disease recovery for patients with the goal of restoring their normal home life.