臺灣預立醫療照護諮商之重要性、挑戰與風險管理研究

A Study of Advance Care Planning's Importance, Challenges and Risk Management in Taiwan

本文主旨在於探討預立醫療照護諮商之重要性、挑戰與風險管理。本文主張預立醫療照護諮商之重要性為：「價值彰顯、多元溝通、自主選擇、證據保全、避免遺憾」。預立醫療照護諮商面臨的挑戰，包含有：「病人自主權利法」施行後與「安寧緩和醫療條例」之間，機制與表單併行（雙軌制）、涵蓋（單軌制）或分類（區分制）的問題；考慮依據預立醫療照護諮商為未雨綢繆型或重大傷病型，提前將預立醫療照護諮商團隊之啟動時機安排為門診時或住院時；與討論預立醫療照護諮商團隊之組成究竟是否須醫師之參與。預立醫療照護諮商面臨的風險管理，包含有：若採取單軌制，預立醫療照護諮商團隊成員之一由醫師擔任為宜；若採取雙軌制，須明定依據「病人自主權利法」與「安寧緩和醫療條例」，機制或表單不一致的確認機制與適用順序；若採取區分制，特定臨床條件之判定標準成為影響病人自主行使機會之關鍵因素。臺灣在病人自主領域之努力成果，奠基於「安寧緩和醫療條例」與未來「病人自主權利法」之落實，可預期再創臺灣繼實施全民健康保險制度後之另一個奇蹟。 The theme of this article is to discuss the importance, challenges, and risk management of advance care planning. The importance of advance care planning is: value highlighting, multiple subjects communicating, free will choosing, evidence preserving, and regrets avoiding. The challenges of advance care planning facing are: between the “Hospice Palliative Care Act＂ and the “Patient Self-determination Act＂ after implementing, should the mechanism and form be paralleled (double track system), covered (single track system), or categorized (separate track system); considering according to precaution taking type or significant injury type of advance care planning, to arrange advance care planning team starting time in advance when outpatient or being hospitalized; and discussing whether a physician should be part of an advance care planning team. The risk management of advance care planning includes the following: it's appropriate to let a physician to become a member of an advance care planning team if single track system is considered; according to the “Patient Self-determination Act＂ and the “Hospice Palliative Care Act＂, conformation mechanism and application order should be regulated when there are mechanism or form inconsistencies if double track system is considered; specific clinical conditions' judgement standards become critical factors affecting patient self-determination exercising opportunities if separate track system is considered. Patient self-determination aria efforts in Taiwan based on enforcement of the “Hospice Palliative Care Act＂ and the future “Patient Self-determination Act＂ is expected to become another miracle after enforcing national health insurance in Taiwan.