醫病共享決策提升住院腎病末期安寧照護成效

Improving Palliative Care Utilization for Hospitalized Patients with End-Stage Renal Disease through Shared Decision Making

目的：依據衛生福利部《非癌末期病人安寧緩和醫療照護指引》與《病人自主權利法》指出，腎臟末期(ESRD)病人應及早進行治療選擇溝通，以促進病人自主與適切照護，本專案旨在運用醫病共享決策(SharedDecision Making, SDM)作為核心干預手段，並以「安寧照護涵蓋率」作為評估成效之量化指標，提升住院ESRD病人末期照護品質。

方法：分析2024年第一季住院ESRD病人安寧照護涵蓋率偏低的原因，並介入策略，包含：(1)建立涵蓋「尚未透析」與「病情不可逆欲撤除透析」情境之標準化醫病共享決策流程；(2)增進醫護人員SDM與末期照護知能；(3)透過圖像化對比選項且具QR code數位化應用之PDAs與制度化流程提升病人/家屬治療選項理解度。

結果：介入後，住院ESRD病人安寧照護涵蓋率由33.3%提升至75.0%，提升幅度達125.2%，且於效果維持期仍穩定達76.0%。

結論：制度化導入SDM流程與決策輔助工具，強化醫病互信與溝通，有助於病人與家屬做出「不違背病人自主、也讓活著的人無憾」的決定。

 

Purpose:According to the Guidelines for Palliative Care of Non-Cancer Terminally Ill Patients and the Patient Right to Autonomy Act in Taiwan, the treatment options for patients with end-stage renal disease (ESRD) should be discussed with these patients early to promote patient autonomy and ensure appropriate care. The project reported herein utilized shared decision making (SDM) as a core intervention and employed palliative care coverage rate as a quantitative indicator of the intervention’s ability to enhance the quality of end-of-life care for hospitalized patients with ESRD.

Methods:The factors contributing to the low palliative care coverage rate among hospitalized patients with ESRD during the first quarter of 2024 were analyzed. Regarding the investigated interventions, (1) establishing a standardized SDM process covering both pre-dialysis decision making and dialysis withdrawal in patients with irreversible conditions; (2) health-care professionals’competencies in SDM and end-of-life care were enhanced; and (3) patients’ and families’understanding of treatment options were improved through institutionalized workflows and PDAs featuring visual treatment comparisons and digital QR code-enabled digital resources.

Results:After the interventions, the palliative care coverage rate among hospitalized patients with ESRD had increased from 33.3% to 75.0%, representing a 125.2% improvement. During the maintenance phase, the rate remained stable at 76.0%.

Conclusion:Institutional implementation of the SDM process and decision aids strengthened mutual trust and communication between health-care providers and patients, facilitating decision making that respects patient autonomy while supporting family members throughout the end-of-life care process.