某社區醫院安寧團隊照護模式初探

An Exploration of Hospice-palliative Care in a Community Hospital

目的：本研究探討安寧照護團隊在某公立教學醫院的照會暨後續服務效果，並以身、心、靈為架構分析個案概況，可作為相同條件醫院的參考。方法：回顧2010年至2011年期間，北部某社區公立教學醫院組織安寧照護團隊，以家醫科醫師為窗口，接受急性病房照會，藉會診方式導入團隊中護理師、社工師、身心內科醫師、麻醉科醫師之專業資源，以身心靈架構提供跨團隊諮詢與協同照護服務。本研究摘錄會談與服務重點，進行資料蒐集與統計分析。結果：42位收案對象，平均年齡為79.2±10.6歲，76.2%有宗教信仰，42.8%合併中風或失智引起之認知異常，47.6%知道自己的診斷，平均有11.5項身體症狀。心理社會問題主要有情緒困擾、疾病認知與適應困難、經濟資源缺乏；靈性宗教問題主要有面對死亡的焦慮與恐懼、存在孤獨與隔絕感、放不下等。收案對象中，身份為公立敬老院住民者有35.7%，經濟資源缺乏的比例為45%。會診時無法尋求家屬會談比例為40.5%，簽署不心肺復甦術意願書比例為33.3%，使得該安寧團隊之社工師、神職人員、志工與護理師的角色相形重要。另外，有宗教信仰者存在孤獨與隔絕感的比例相對較低；公立敬老院住民個案經濟資源缺乏與面對死亡的焦慮恐懼比例相對較高，且本人簽署預立選擇安寧醫療意願書的比例相對較高；非公立敬老院住民由家屬代為簽署不施行心肺復甦術同意書的比例較多。結論：公立社區醫院的安寧照護系統，需要經驗豐富的安寧療護跨團隊專業人力介入，且鑑於服務對象相對高齡，更突顯老年醫學與安寧照護善巧融合的重要性。

Objective: The study provided an analysis of an experimental multi-disciplinary service model of hospice-palliative care in a public community hospital. Methods: We reviewed the records of patients who were referred from acute ward teams for hospice-palliative care consultations in a public community hospital. Body, mind and spiritual conditions were assessed to determine the bio-psycho-social and spiritual needs of terminal patients. A total of 42 terminal inpatients from 2010 January to 2011 December were reviewed. Results: The average age of these patients was 79.2±10.6 years; 76.2% identified a religious preference, and 42.8% had cognitive impairment due to a cerebral vascular accident or dementia. Only 47.6% knew their diagnosis and prognosis. The average number of physical symptoms was 11.5, and these included weakness, fatigue, loss of appetite, abdominal distension, infection, and incontinence. The major psychological problems of patients and families included emotional distress, adaptation difficulties, and lack of economic resources; the main spiritual issues included anxiety and fear of death and a sense of loneliness and isolation. Of these patients, 35.7% had previously lived in a public nursing home and this was associed with a lack of economic resources (45%), the inability to seek consultation with family members (40.5%), and signed a DNR request by themselves precedently (33.3%). They raised the lack of economic resources and the feelings of anxiety and fear of death as concerns; however, a religious belief lowered their sense of loneliness and isolation. Conclusions: A professional multi-disciplinary hospice team is essential if a public community hospital is to build a hospital-palliative care system. The integration of geriatric care and palliative care is also important.