2021年10月12日 星期二

外賓演講提問-1101001榮民體系安寧緩和醫療全程照護網絡國際研討會

1101001榮民體系安寧緩和醫療全程照護網絡國際研討會
外賓演講中英文提問

Sheila 教授演講提問-中文版本

提問1請問在英國照顧臨終住民的人力比為何?是否有分級制度?和政府補助層面?

Sheila教授回答:據我所知,療養院並沒有具體的人員配備要求,儘管每個班次都有一名護理師值班。大多數為居民提供個人護理的護理助理不是合格的護理師,但他們可能已經完成了一些實務訓練,稱為 “National Vocational Awards ”(國家職業認證)。英國的大多數療養院都是營利性組織,它們不直接由政府資助(它們不是國家衛生服務的一部分)。老年人需直接支付療養院床位的費用,除非他們很窮。他們的醫療由政府資助的全科醫生提供。然而,一些療養院也有設有專門的病床用於安寧緩和照護和臨終關懷,這些床位由額外的由政府提供津貼,這些床位也有額外的編制人員。

提問2:UK 的機構是否普遍願意接受住民在機構安寧照顧至死亡,而不會傾向將他們轉出?

Sheila 教授回答:有強大的政策影響,使住在療養院的老年人能夠盡可能長時間地留在這些組織中,包括在生命末期直到死亡。死於療養院而非醫院的人數逐年穩定增加。目前大約 17-20% 的人死在療養院,約50%的人在醫院死亡。療養院仍會接收年長者,即使他們已接近生命盡頭,而且即使這些年長者即將死亡,他們不會常規地被轉移到醫院,除非有充分的醫療理由。

 

提問3:講者提到的安寧相關知能技巧似都著重在醫護專業人員。臨終患者和家人之間的關係更為密切,請問國外對於家屬的部份,是否也有類似針對醫護專業人員的機制?

Sheila 教授回答: PACE計畫中,我們專注於支持護理師和護理助理提高療養院安寧緩和照護的質量,包括他們的福利,以及讓他們更有信心照顧臨終者。在第 6 步驟中,我們專注於“Debriefing meetings”(匯報會議),所有療養院工作人員都在會上討論了每位居民死亡的影響,分享他們認為進展順利以及可以改進的部分。它還提供了在小組內分享他們的悲傷與哀思的機會。在 PACE 計畫中,我們並沒有關注家庭成員的支持需求,但這是一個重要的課題,目前我的同事,Lancaster大學的Nancy Preston教授也正在進行此方面的研究。

 

提問4:在英國或荷蘭如果遇到意識清楚,卻表達不清的病人,他們的照護者是如何溝通的?

Sheila 教授回答:我們鼓勵家庭成員和醫護人員,與患有或未患有癡呆症的老年人使用各種形式的交流。舉例來說,使用觸摸,例如撫摸他們的手或進行手臂按摩;也可以使用聲音,例如播放他們喜歡的音樂;也可以使用嗅覺,例如在精油擴香儀中使用精油或手油;或是使用味覺,例如給予一小口他們最喜歡的食物、零食或水果。

  

提問5:可以與安寧者本身討論他的生命即將到來嗎?會造成更大恐慌或是可以讓他提出他最終想要作的事情?

Sheila 教授回答:如果一個人被轉介到英國的臨終安寧照護,我們總是會談論他們的臨終偏好,並公開承認他們會死亡。安寧照護包含了提供症狀處置、喘息服務以及臨終關懷等部分,在大多數安寧照護中,超過50%的患者會出院回家。在安寧照護護理師和醫師的支持下,其中一些患者將在家中死亡。如果談話節奏輕緩,並且我們對患者對信息的期望夠敏感的話,患者便不會驚慌或變得非常痛苦。

 

Sheila 教授演講提問-英文版本

Q1: What is the approximate manpower ratio of long-term care institutions in the UK to care for dying residents? Is there a grading system? Does the government provide financial subsidies?

Professor Sheila: There is no specific staffing requirement in nursing homes that I am aware of although all will have a registered nurse on duty on every shift.  Most personal care for residents is provided by care assistants who are not qualified nurses but they may have completed some practical training called National Vocational Awards. Most nursing homes in the UK are for-profit organisations and they are not directly funded by the government (they are not part of the National Health Service). Older people pay directly for their bed in a nursing home, unless they are very poor. Their medical care is provided by GPs who are funded by the government. However, some nursing homes also have dedicated beds for palliative and end-of-life care. These beds are financially supported by additional government allowances and this means there is extra staffing available.

 

Q2: Are institutions in the UK generally willing to accept residents in the institution's peaceful care to death, rather than tending to transfer them out?

Professor Sheila: There is a strong policy drive to enable older people living in nursing homes to remain in these organisations for a long as possible, including during end of life and to die there. There has been a steady increased in the number of people who die in nursing homes rather than hospitals. Currently about 17-20% of people die in nursing homes and just over 50% in hospitals. Nursing homes will accept older people even if they are near the end of life and they do not routinely transfer them to hospital if they are dying, unless there is a good medical reason.

 

Q3: The well-being skills you mentioned seem to be focused on healthcare professionals. The relationship between dying patients and their family members is closer. Is there a mechanism for family members to learn related knowledge and  skills?

Professor Sheila: During the PACE project, we focused on supporting nurses and care assistants to improve the quality of palliative care in nursing homes, including focussing on their welfare and enabling them to become more confident to care for dying people. In Step 6, we focused on ‘Debriefing meetings’ where all nursing home staff talked through the impact of each death of a resident, to share what they felt went well and what care they could improve. It also gave an opportunity to share their feelings of sadness and grief within the group and helped them to better acknowledge the loss. So during the PACE project, we did not focus on the support needs of family members but this is an important topic and is currently being researched by my colleague Professor Nancy Preston at Lancaster University.

 

Q4: In the UK or the Netherlands, if you encounter a patient who has a clear consciousness but can't express clearly, how do their caregivers communicate?

Professor Sheila: We encourage family members and healthcare workers to use all forms of communication with older people who either have or do not have dementia. For example, using touch such as stroking their hand or giving an arm massage, also sounds such as playing music that they like, the sense of smell, such as using essential oils in a diffuser or hand oils, sense of taste, such as giving a small mouthful of their favourite foods or snacks or fruit.

  

Q5: From your point of view, can you discuss with the person receiving hospice care that his life is about to end? Will it cause greater panic or allow him to propose what he ultimately wants to do?

Professor Sheila: If a person is referred to a hospice in the UK, we always have a conversation about their end of life preferences and an open acknowledgement that they will die. However, hospices provide symptom management and respite care as well as end of life care, so in most hospices over 50% of patients are discharged home. Some of these patients will die at home with support from hospice nurses and doctors. Patients do not panic or become very distressed if the conversation is paced gently and we are sensitive to the patient’s wishes for information.


Mitchell 教授演講提問-中文版本

提問1請問在澳洲是有安寧緩和專門機構?還是在一般機構中設有安寧緩和部門?

Mitchell教授回答:在澳洲,提供安寧緩和醫療的方式有許多。在醫院內的服務有包括專門的安寧病房,也有為院內其他單位提供建議的會診團隊,或二者結合。在社區裡,有主要由宗教團體資助獨立機構,也有以社區為基礎的組織。這類機構大部分與政府有簽約,為無法負擔費用的人提供服務。醫院也有延伸到社區的服務。很多提供社區護理的服務都具備緩和照顧技巧。理想上,這些服務都應該進行適當的協調,使得提供的照護有效率且合乎成本效益。


提問2請問安寧緩和專家是否會與機構中照護病人的醫師、護理師或其他人員討論病人的預立醫療照護計畫?

Mitchell教授回答:要確保每個醫療專業人員都了解預立醫療諮商且能鼓勵他們的病人尋求服務,需要花很大的力氣。預立醫療決定通常由護理人員在醫院、安養院或基層診所完成。在基層診所,75歲以上的民眾有補助健康檢查,其中有一部分就是提出預立醫療諮商的議題。大多數的老人安養院在入住的時候,會進行預立醫療諮商,且提供給該安養院。因此當有情況出現時,早已有了預立醫療決定。


Mitchell 教授演講提問-英文版本

Q1: Are there institutions especially for palliative and hospice care in Australia? Or the palliative and hospice care department is a part of a hospital or health care institution?

Professor MitchellThere is a spectrum of means by which palliative care is delivered to patients.  Within hospital services include dedicated wards, outreach teams advising other units of the hospital, or a combination of both.  In the community there are separate institutions funded mainly by religious organisations, but also community based organisations. Most of these have contracts with government to provide services to people who cannot afford the cost themselves.  There are outreach services from hospital services to the community. Many services that provide community nursing have palliative care skill. Ideally, each of these services should be coordinating their care so that care is delivered as efficiently and cost-effectively as possible.


Q2: Will the specialists in Australia discuss advance care planning with the physicians, nurses, or other caregivers who take care of the patients?

Professor Mitchell: There is a lot of effort going in to ensuring that all health professionals are aware of advance care planning, and encourage their patients to seek that care. Advance health directives are often completed by nurses in settings as widespread as hospitals, aged care homes and general practices. In general practice, we are funded to conduct health checks on people over the age of 75, and part of this is raising the issue of advance care planning. Most age care facilities will offer doing an advance care plan on admission to the facility, so it is there when complications arise.

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