理想與現實中的預立醫療決定

Ideal and Realistic Advance Decisions

不論是國外經驗或是我國在《病人自主權利法》試辦計畫下之臨床現場觀察，皆可預見預立醫療決定難以成功地實踐病人自主，因為民眾傾向對於醫療選擇表達一個模糊的價值觀而非精確的決定，也無法呈現病人在接受資訊與做決策過程中的情緒需求和影響。若臨床疾病改變了病人的心智能力，其選擇是否仍與病前同一，關鍵利益及體驗利益衝突時應該如何處理，將使得做為一種延伸病人自主意願的預立醫療決定，在臨床情境上難以落實。雖然《病人自主權利法》賦予預立醫療決定法效力，但它並不是一種萬靈丹，也不等同於病人自主的核心概念與價值。本文建議，我國在法律和給付政策上，必須將預立醫療照護諮商與預立醫療決定脫鉤；執行上，必須透過醫師與病人持續地對話，才能落實預立醫療決定在臨床上的應用與價值。

Both experiences from all over the world and clinical observations from the Patient Autonomy Law pilot program allow us to foresee that advance decisions are difficult to be practiced because patients tend to express a vague value for medical decisions rather than accurate medical options. In addition, their emotional needs and effects on decision-making cannot be clearly shown in the process of receiving information. If a patient’s mental capacity declines in the clinical process, can the consistency of his/her medical wishes be ensured? Although the Patient Autonomy Act gives the advance decision legal binding power, it is not a panacea, nor is it the core concept and value of patient autonomy. This paper suggests that the laws and policy of insurance payment systems be committed to advance care planning rather than advance decisions. Communication between the doctor and the patient should be kept to guarantee the value and the clinical application of the advance decision.