Palliative Care in Home-care Settings in Japan 1/2

In this session, I would like to talk about current situation of home-based medical care in Japan, advance care planning recommended by the central government, and palliative care performed for terminally-ill cancer and non-cancer patients in home-care settings.

After the World War II, number of deaths in hospitals had been continuously increased in Japan, on the contrary, that at home had been steadily decreased until 2005. After 2005, the number of deaths at home is gradually on the rise, probably due to the increase of patients receiving home-based medical care. Majority of older Japanese hope to continue to live and get medical care at home, if possible, until their death.

Benefits of public health insurance for home-based medical care services are exclusively given to disabled patients unable to go to medical institutions. Basic structure of home-based medical care is composed of ①visits of physicians or nurses on regular basis, and ②consultation services around 24 hours in addition with emergency visits, if necessary. Sophisticated public health insurance systems provide cost for frequent visits of physicians, relatively expensive care such as artificial ventilation and total parenteral nutrition in the home-care settings. Multidisciplinary collaboration of medical and caregiving personnel is carried out owing to public insurances and welfare systems. Home-based palliative care is conducted in this context.

Palliative Care in Home-care Settings in Japan 2/2

Promotion of advance care planning (ACP) in Japan was initiated around 2018, much later than other developed countries. Although some highly motivated heath care providers try to assist patients to make their advance care plans appropriately, this kind of activities is not yet popular enough. ACP is recognized as especially important in cases receiving home-based medical care. Sad to say, ACP is frequently misunderstood to get consent to orders not to attempt resuscitation. As is often the case with older Japanese, some patients are reluctant to speak out directly their desire and their preferences. This tendency is unique character of Japanese people strongly based on culture and traditional way of thinking. Therefore, those older persons prefer to communicate implicitly and think such way of communication is beautiful. In these cases, it is difficult to discuss about ACP openly, especially in meetings attended by various care providers.

Technology and skills of home palliative care is already prevalent throughout Japan, and commonly employed in care of terminally-ill patients with malignancy. Opioid preparations can be administered through various routes for cancer patients in home, however, on the other hand, there is severe restrictions of opioid usage for non-cancer patients in Japan.

We are tirelessly trying to improve quality of home-based palliative care and associated health care systems in a bid to improve quality of life of patients in home-care settings.

Rethinking Advance Care Planning in the

Post-Pandemic Era

COVID-19 sparked an interest in Advance Care Planning (ACP). In this context, the goal of ACP was largely seen as being able to facilitate goal concordant care. However, many well-conducted trials have failed to show that ACP improves goal-concordant care at the end of life or improves patient quality of life or reduces healthcare costs. Thus, ACP does not seem to change patients' end of life trajectory or care.

Why is that so and what then is the purpose of ACP in today’s world?

In this talk, I will speak about the challenges of implementing ACP and of providing goal concordant care. I will propose new objectives for ACP and some indicators to measure its success.

Non-Cancer Palliative Care:

Emergency Department Palliative and Nursing Home

palliative experiences from Singapore

Palliative Care is important to improve patient's quality of life and reduce their symptom burden. It is also important in reducing acute healthcare utilisation and in allowing patients to be cared for in their preferred place of care.

In this presentation, Dr Laurence will share on the current gaps in non-cancer palliative care and Singapore's experience in implementing palliative care in the emergency department and at the nursing homes.

以終為始- 超高齡社會中老人的連續性照護

台灣在預計將在2025 年成為超高齡社會（老年人口占比大於 20%）， 銀髮海嘯帶來健康照護的費用高漲，在現行醫療模式中對多重共病者的服務片斷化，以及生命晚期維生醫療資源使用的沉重，無法帶來生活品質的提升， 卻加速了醫療體系崩壞的可能。

為了促進在地老化與善終的願景，醫療照護體系應思考並進行典範移轉，重新調整資源的配置，應推動強調人本自主的預立醫療照護計畫(Advance Care Planning，ACP)，建構在宅連續性照護體系(Home-based Care Ecosystem)，倡議慈悲關懷社區(Compassionate Community)，才是超高齡國家面對挑戰的核心因應策略。

後疫情時代安寧療護團隊的復原力

全球COVID-19疫情使醫事人力常處在高壓力的工作環境中，而安寧團隊人員經歷的恐懼、焦慮、悲傷和壓力，導致人員產生痛苦和倦怠，不僅影響人員的健康和幸福感，也影響其所提供的照護，因此降低人員因應COVID-19工作壓力對健康所產生的衝擊，建立復原力(Resilience)是一個很重要的議題。

復原力是一種積極動態過程，其不僅是一種正向處世態度，同時亦是一種有效處理面對逆境的適當策略，使人面臨高度壓力與逆境時能迅速復原心理狀況(bounce back)的一種正向思考能力。安寧團隊人員在極端高壓的工作環境中，藉由推動與落實復原力所賦予之正向態度，將可協助人員在醫護場域中維持工作專業度與高度幸福感。

後疫情時代之推廣社區型生命識能(Pre-ACP)模式

2020年全球發生大規模的新冠疫情，截至今日有上百萬人民的性命與健康在此疫情之中喪失與損傷。臺灣於新冠疫情中，已是前段績優的國家，然仍有數千位的國民離世，對於「生命」議題更需從前端進行規劃與思考。有鑑於此，臺北市立聯合醫院於2019年病人自主權利法施行以來，已協助1萬多名意願人參與預立醫療照護 諮商(以下簡稱ACP)。而民眾於ACP的前思考期，更是為本院積極進行推展的目標。

推展模式依據服務據點的屬性，而運用不同的地點推展策略。將於本次研討會中分享里辦公室、宮廟、日照據點、機構等推展模式。

未來衛福部長照委員會規劃使用長照日間服務者，為參與ACP之重點對象。對於預立醫療照護諮商不單僅存於醫療單位內，更進展至社區端，尤其社區為福利之綠洲，更需扎根於社區內。因此以醫療單位推展量能與性效比，長照機構安養型較佳，其次以里辦公室，而機構、里辦公室之人員為關鍵角色，唯有熟悉與意願，方得推展得宜。

安寧療護工作人員的自我照顧－以慈心疲憊為主題

安寧療護強調五全照護，重視生命末期個案生心社靈的照護，其中「陪伴」與「慈心同理」是安寧工作者重要的心法。然而，同理心的投入不僅耗能，亦使安寧工作者與個案之間的界線模糊，使自身容易處於身心負面反應的風險之中。

慈心疲憊（compassion fatigue）意指安寧工作者在助人歷程中，感同身受且專注於個案的創傷所出現的生理心理症狀，為一種關懷他人情感痛苦的代價，亦被視為「次級創傷壓力（Secondary Traumatic Stress, STS）」。因此，良好的自我照顧、靈性照顧、環境支持及適時求助為安寧工作者需時常提醒自己的重要事項，不僅較能預防慈心疲憊的發生，更能心有餘裕陪伴生命末期個案走完生命最後一哩路。