陳心怡CHEN, HSIN-YI潘欣婷POON, YAN-TINGYAN-TINGPOON醫學社會暨社會工作學系碩士班2026-10-052024-01-0820242024-01-03https://handle.ncl.edu.tw/11296/6wk98whttps://scholars.csmu.edu.tw/handle/123456789/20554背景：失智症患者的疾病歷程具有獨特性，患者會隨著疾病發展而逐漸喪失自主決策能力，難以為自己作出醫療決策。從人權角度來看，失智症患者的病人自主權利應被同樣予以重視。本研究目的是探討社會工作者在促進失智症患者制定預立醫療自主計畫的實務現況以及介入模式。方法：本研究為質性研究，以半結構式訪綱訪談15位社會工作者，進行資料蒐集，研究對象為目前或曾經從事服務失智症患者相關領域之社會工作者，並且至少在各服務單位中訪談一名社會工作者。八個服務類別包括在「醫療端」的醫務社工，以及在「社區端」的社工：失智共同照護中心、失智社區服務據點、社區整合型服務中心（長照A據點）、複合型服務中心（長照B據點）、巷弄長照站（長照C據點）、長者機構服務，以及家庭照顧者服務。研究結果：及早開啟預立醫療照護諮商（ACP）的對話對失智症患者與家屬具有意義。透過預立醫療照護諮商和簽署預立醫療決定書，促使失智症患者在尚有自主決策能力時，及早與家屬和醫療決策代理人討論個人對於特定醫療決定的意願偏好，達成家庭共識，以保障患者的病人自主權。此外，研究發現目前醫療端社工具備一套工作流程以及輔助工具，並以「最大協助原則」輔助仍具備意思能力的患者表達其對醫療的想法和意願，而非由家屬替代患者作決定。社區端社工則以生命回顧課程、社區宣導ACP以及轉介的方式，以協助患者接觸ACP相關資訊。再者，本研究整理出目前社會工作者在失智症患者參與ACP的專業角色與任務。醫療端社工的角色包括：宣導者與倡議者、ACP資訊及ACP服務的提供者、跨專業團隊的協調者以及轉介者；社區端社工的角色包括：日常照顧及情緒支持的服務提供者、生命教育宣導者以及轉介者。最後，研究者進一步整理受訪者在有關工作流程上和專業知能上的建議，包括及早讓失智症患者開啟醫療決策的討論，並將ACP嵌入失智症服務的工作流程中，甚至把醫療決策的討論融入日常生活，與此同時，提升醫療端及社區端社工的相關知能，社區宣導時亦可以從安寧概念帶到ACP的概念。另一方面，研究者整理受訪者在有關系統上、跨領域和跨專業的合作模式上的建議，包括以試行計畫吸收經驗，並建立流暢的工作流程，發展醫療端和社區端的合作模式。除此之外，政策面的配合亦十分重要，投入人力資源、ACP的經濟補助有助，以及提升醫療團隊對ACP的知能和敏感度，以跨專業團隊合作，才能有效推動失智症患者的ACP。結論：在失智症患者仍具備理解、記憶、溝通以及衡量四個面向的能力時，社會工作者應以最大協助原則輔助患者運用剩餘能力行使個人的決定權，並表達自己期待的醫療選項。建議將ACP的討論納入失智症患者服務中必要的工作流程，並將失智症患者優先納入ACP補助和免費的對象中。另外，社會工作者應具備華人文化敏感度看待醫療決策，由於華人的文化強調以「家庭為中心」，ACP的討論並不應局限於在醫院內簽署正式法律文件，社區和家庭中非正式的ACP討論也是具有意義，因此建議以社區為基礎推動失智症患者的ACP。最後，跨專業及跨領域的專業人員具備討論ACP的知能將會成為宣導ACP的種子，建議建構跨專業及跨領域的教育訓練以因應失智症患者參與ACP的需求。The illness trajectory of people with dementia is unique, which involving a gradual loss of decision-making capacity as the disease progresses, and it challenging for patients to make medical decisions for themselves. From a human rights perspective, the autonomy of people with dementia should be equally valued. This study aims to explore the current practices and intervention models of social workers in promoting the discussion of advance care planning (ACP) for people with dementia.Methods: This qualitative study conducted semi-structured interviews with 15 social workers engaged in dementia-related services, either currently or in the past. Participants were selected from eight service categories, including medical social workers in the healthcare sector and community-based social workers, such as dementia integrated care center (DICC), dementia community service sites (DCSS), community-based integrated service centers (Tier A), combined service centers (Tier B), and long-term care stations in alleys and lanes (Tier C), residential care service and family caregiver services.Results: Early initiation of ACP discussions was found to be meaningful for people with dementia and their families. Through advance care planning and the signing of advance care directives, patients were encouraged to discuss their personal preferences with family members and healthcare decision agents while still possessing decision-making capacity. The conversation facilitated family consensus and safeguarded the patient's autonomy.The study also revealed that medical social workers in the healthcare sector have established workflows and support tools, assisting patients with remaining decision-making capacity in expressing their thoughts and wishes regarding medical decision, rather than having decisions made by family members. Community-based social workers utilized life review courses, community promotion of ACP, and referrals to connect patients with ACP-related information.The roles of social workers in patients' engagement in ACP were categorized. Medical social workers served as advocates, ACP information providers, coordinators within interdisciplinary teams, and facilitators of referrals. Community-based social workers provided daily care and emotional support, life education advocates, and referral agents.Recommendations for improving workflows and professional competence were provided, emphasizing early initiation of medical decision discussions, integrating ACP into dementia service workflows, embedding medical decision discussions into daily life, enhancing the relevant knowledge and skills of medical and community-based social workers, and promoting the concept of ACP during community advocacy.Recommendations for system-level, interdisciplinary, and cross-professional collaboration models were provided, trial programs and workflow optimization, collaboration models between medical and community sectors, policy-driven human resource investment, financial support for ACP, and enhancing medical team knowledge and sensitivity.Conclusion: Social workers play a crucial role in assisting dementia patient with remaining cognitive abilities to exercise their decision-making rights. It is suggested to embed ACP discussions into dementia service workflows, and prioritize people with dementia for ACP subsidies and free service. Social workers should possess cultural sensitivity on medical decision-making. The discussions on advance care planning are not confined to formal legal documents signed within hospital settings, but also the informal ACP discussions within communities and families are significance. It is recommended to promote ACP for dementia patients on a community basis. Lastly, professionals with interdisciplinary and cross-domain expertise in discussing ACP serve as the seeds for advocating ACP. It is suggested to establish educational training to better equip professionals in handling ACP participation among people with dementia.失智症預立醫療照護諮商醫療決策自主性社會工作者DementiaAdvance Care Planning (ACP)medical decision-makingautonomysocial workersthesis