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。
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。
Sheila 教授回答：在 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。
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.
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 Mitchell: There 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.