衛生福利部醫病共享決策平台
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決策輔助工具摘要表

我或家人面對呼吸衰竭插管卻拔管困難的時候,該接受氣切手術嗎? 最新更新日期:2020年09月26日
科別 胸腔內外科
主題類別 3. 呼吸系統
決策類型 治療
關鍵字 氣管內管插管(tracheal intubation),氣管造口術(tracheostomy),呼吸器脫離訓練(ventilator weaning training),慢性呼吸器依賴(ventilator dependence)
適用病人條件 1. 呼吸器病人經積極治療2週後,經治療團隊評估仍未適合進入呼吸器脫離程序者。 2. 呼吸器病人呼吸器使用大於3週者。 3. 其他使用呼吸器不滿2週,但經治療團隊評估需長久呼吸器依賴使用者。
可供選擇決策方案 持續經口/經鼻氣管內插管,接受氣切手術
使用場所 病房、其他
執行者 醫師、護理師、衛教師、個案管理師
開發團隊、機構 高雄榮民總醫院 重症加護醫學內科
團隊成員
版本
輔助工具研發過程說明 礙於國情與民情的因素,雖然氣管造口術相較於延長氣管內管插管使用有較多的優點且較少之合併症發生,還是一直難為普羅大眾於第一時間接受,當中錯得不能再錯,卻廣為流傳的說法諸如氣切後就一輩子難以脫離機器或氣切後要終身臥床的錯誤論點,或是對於鍾愛之親屬身體完整性維護的取捨。本中心因面臨臨床上述諸多挫折,卻苦於缺乏具有系統性且完整的題材,故於參照前人經驗筆談及酌以實證證據之提供,希望能給予病人及家屬完整且正確的氣管內管插管以及氣管造口術訊息,以利其做出真正對於病況及臨床有幫助的決定。
相關題材內容及決策輔助工具的雛形建置,本中心成立推動小組,並邀請多職類人員組成團隊參與討論,當中包括重症加護內科、重症加護外科、心臟內科、胸腔內科、感染科、一般外科等各專科醫師,專科護理師、護理師、呼吸治療師、藥師、社工師等,且照護團隊亦由急性重症照護的加護病房團隊,延伸至亞急性呼吸照護病房團隊,乃至一般病房及出院後準備小組等團隊成員參與,希望能立足於實證醫學證據之上,提供完整且連續的各環節評估以及完整的相關訊息,給予面對此重大決定的病人或病人家屬決策的幫助,做出最合乎他們綜觀各面向考量的合適決策。
於前版文件建立後,團隊成員廣泛的運用於急性、亞急性、乃至於一般病房等符合適用病人條件的病人及病人家屬,且亦得到相對應相關符合適應症病人中氣切比率之改善上升,間接提高相關呼吸治療之品質參數。而陸陸續續由問卷以及病人或病人家屬甚或是相關從業各職類專業人員之反饋,對於前版之決策輔助工具內容予以修編,形成最新版本之輔助工具,並依前版之諸多缺漏及使用者意見予以編修,讓每一個人,都能得到訊息的全貌,做出最合乎需求的決定。
根據目前最佳的證據,病人一旦進入慢性呼吸器依賴狀態,其出院死亡率,出院後一年內死亡率皆比非慢性呼吸器依賴狀態病人為高,且相關風險大幅受到面臨氣切決定時(住院21天)年齡、面臨氣切決定時(住院21天)是否仍使用升壓劑、面臨氣切決定時(住院21天)是否為急性腎衰竭須洗腎狀態、經評估無法脫離呼吸器診斷、住院時就有慢性腎臟疾病相關診斷、共病因子、及糖尿病等診斷影響。但雖預後不佳,當中仍有20%病人能夠出院返家,甚至當中有一半的病人能夠經由適當的治療和幫助得以脫離呼吸器。此次改版提供相應影響病人預後的相關因子說明,且幫助了解治療決定,權衡帶來的好處與可能造成的壞處,評估當下病人的狀況及預後,審慎衡量幫助及副作用,讓關心與愛,不造成傷害。
此外,本院將醫病共享決策過程融入醫囑系統,讓醫師開單便利,使民眾能更快速取得所需的輔助工具資料。不僅提升使用率、更強化醫病溝通。透過開立檢查驗碼後送出醫囑,可列印出專屬病人之QR-CODE,病人或家屬藉由手機掃描QR-CODE進入系統,通過驗證後填寫內容送出,醫師端可於病歷系統內,進行讀取動作並提供適當處置。
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醫病共享決策介紹
醫病共享決策(SDM)緣起
醫病共享決策輔助工具介紹
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