超高齡社會之安寧緩和居家醫療與在宅急症照護

Palliative Home Care and Hospital-at-Home in a Super-Aged Society

隨著台灣邁入超高齡社會，如何發展整合性的居家醫療模式已成當務之急。本文探討安寧緩和居家醫療與在宅急症照護的結合，作為兼顧醫療品質與滿足病人在宅善終期待的可能解方。居家醫療生態系概念指出，在宅急症照護（hospital at home, HaH）能有效串聯各種居家服務，填補照護斷點，對於多重慢病與衰弱高齡病人非常重要。台灣目前安寧緩和居家醫療，在健保制度支持下已具相當規模，並在國際評比中屢獲佳績，但仍面臨給付誘因不足、專業人力教育有限，及急症支援服務不全等挑戰。透過在宅急症照護的導入，可望提供即時急症處置、提前介入預立醫療照護諮商（advance care planning, ACP）、促進早期安寧緩和醫療介入，並強化病人轉銜照護的連續性。國際經驗顯示，包含24小時支援系統、跨專業教育訓練、社會大眾宣導教育等，皆有助於提升居家急症照護的接受度與照護品質。特別是在安寧居家病人中，急性感染、貧血、腹水、呼吸困難等急症處置需求頻繁，若能透過HaH模式在家即時處理，將大幅降低不必要住院與急診轉送，提升病人與家屬滿意度，並促進以家庭為中心、尊嚴善終的照護模式。本文呼籲未來應整合健保與長照資源，建立彈性且具誘因的支付制度，強化臨床教育與模擬訓練體系，並透過社會教育重建大眾對「家」作為終老之地的信任。安寧緩和居家罄療與在宅急症照護的結合，不僅是醫療模式的革新，更是一場回歸生命尊嚴與人性溫度的社會轉變，對於即將面臨高齡挑戰的台灣具有重要啟示。

As Taiwan enters a super-aged society, the demand for integrated home-based healthcare models becomes increasingly urgent. This paper explores the intersection of palliative home care and hospital-at-home (HaH) services as a potential solution to balance medical quality and patients’longing to remain at home. Homebased medical ecosystems, as proposed by Ritchie and Leff, emphasize the role of HaH in bridging care gaps, particularly for older adults with complex comorbidities and frailty. While Taiwan has developed a robust palliative home care system supported by national health insurance, challenges remain, including limited financial incentives for healthcare providers, insufficient education and training for new practitioners, and inadequate acute care support at home. The integration of HaH offers new opportunities for rapid response to acute conditions, timely advance care planning, and smoother transitions into early palliative care. Drawing on international experiences from Europe, the United States, and Japan, the paper highlights the importance of 24-hour medical support, interdisciplinary training, and public education to enhance both professional capacity and societal acceptance of home-based acute care. Among palliative home care patients, acute conditions such as infections, anemia, ascites, and dyspnea are common and often require timely intervention. The implementation of the HaH model to manage these conditions in the home setting could substantially reduce unnecessary hospital admissions and emergency department visits, enhance patient and family satisfaction, and support a family-centered, dignity-conserving approach to end-of-life care. We advocate for the integration of National Health Insurance and long-term care resources to establish a flexible, incentive-based reimbursement system, strengthen clinical education and simulation training, and promote public awareness to restore trust in the home as a place for dying with dignity. The convergence of palliative home care and acute home-based medical services represents not only an innovation in healthcare delivery but also a societal shift towards preserving human dignity at the end of life—offering important insights for Taiwan as it confronts the challenges of population aging.