預立醫療照護諮商的本土文化適應性及面對心智能力受損者之挑戰──以高雄醫學大學之經驗為例

The Implementation of Culturally Adapted Advance Care Planning and the Challenge for People with Impaired Mental Capacity in Taiwanese Context: Experiences from Kaohsiung Medical University

亞洲首部《病人自主權利法》已在臺灣生效上路，希望能尊重病人醫療自主、保障其善終權益並促進醫病關係和諧。本文以高雄醫學大學附設中和紀念醫院執行預立醫療照護諮商之經驗與反思，針對臺灣本土脈絡下的「文化適應」（culturaladaptation）與面對「心智能力」（mental capacity）受損者之挑戰進行論述。文化適應被認為是成功鑲嵌新式醫療照護服務於常規照顧之關鍵。在臺灣，預立醫療照護諮商過程需由跨專業團隊依照意願人與家屬的健康識能（health literacy）程度以及準備度，進行以「家庭」為中心的個別化引導。面對心智能力受損者的預立醫療照護諮商與決策，臨床人員應對個人之剩餘能力給予最大協助，以達成其「支援性決策」，維護其自主參與及決定之權利。政府機關與機構應提供政策與資源的支持，確保合宜的服務執行與研究，並思考法律上通盤的增修。最後，廣泛的民眾教育以及各級健康照護人員的培訓更是當務之急。

Recently, there is a trend of advocating the patient’s autonomy on medical decision-making in Asia. This made Taiwan the first country in Asia adopting the Patient Right of Autonomy Act to highlight the importance of patient’s autonomy on medical care in a trusting clinician-patient relationship for the ’good death’.This article elucidated the experience of advance care planning (ACP) implementation and reflected the challenges regarding different clinical scenarios and decision-making process for people with impaired mental capacity in ACP discussions at Kaohsiung Medical University Chung-Ho Memorial Hospital. Cultural adaptation is key to embed a novel healthcare intervention into routine care. In Taiwan, ACP encompasses multi-discipline team who provide ’family-centered’ care to meet individual’s needs according to the health literacy level and readiness of an individual and their family members. For people with impaired mental capacity, healthcare professionals should endeavour to assist the individual to make his/her own decisions (supportive decision-making) rather than make decisions for him/her (substitute decision-making). Government and institutions are urged to prompt policy support, secure funding or grant for clinical practice and research, and initiate the amendment or establishment for comprehensive legislation. Providing relevant education for the general public and designing training programmes for medical staff are imperative.