全人醫療 急診醫學科 蕭政廷醫師 2015.05.20
民眾需要的不是醫療而是健康 最帥的衛生所主任 徐超斌 急診專科醫生
什麼是健康 WHO: “Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.”
在成為醫師照顧別人的健康前 你應該 Be aware of yourself Take care of your own needs
課程大綱 何謂全人醫療？ 全人醫療在專科的運用 全人醫療與六大核心能力
HEALTH & HOLISTIC HEALTH Health is a person’s physical well-being. Holistic is from the Greek word holos, meaning whole. Holistic health views the physical, intellectual, sociocultural, psychological, and spiritual aspects of a person’s life as an integrated whole.
衛福部: 全人照護（Holistic Health Care） 係指不僅強調生病後提供以病人為中心之醫療照護，也要在生病前提供正確有效的預防方法」。 而「全人健康照護體系」指提供 1. 全人（包括生理、心理、社會及心靈層面） 2. 全民（每一個人都可以得到）基本保健醫療（包括預防保健、疾病診治、長期照護及安寧照護）的照護系統（從基層至二、三級醫療的整合） 3. 「病人為中心」之整合性預防、保健、醫療為導向，提供以個人為中心，家庭為單位，社區為範疇之整合性、協調性、持續性的預防保健及醫療照護，暨以良好互動之醫病關係，進而達到落實執行『全人健康照護』的理念
何謂全人醫療？ Whole person care, whole person medicine Total patient care Holistic approach to patient care, holistic care Holistic medicine
Whole Person Care 包含醫療、社會、心理及經濟層面 The whole person 是指生命的四個層面： 身體、情緒、心智、能量狀態 照顧“the whole person”需整合性健康照護 生理(身體)、心理、社會 Engel G, Science, 1977
Total Patient Care 藥理治療+ 處理社會及環境的問題 Tettenborn & Kramer, 1992.
Holistic Approach to Patient Care Holistic care 涉及身體、心理、社會及心靈 其中以心靈層面最常被忽視；心靈的照顧與身體、社會及心理的照顧是分不開的 整合性健康照護: 精良醫術、尊重病患隱私、建立良好醫病關係 BayersJF, AACN Clinical Issues, 1997.
Holistic Medicine 以evidence-based為前題，整合 complementary & alternative medicine、holistic medicine 及conventional medicine 某種以治療方法來定義holistic care 的醫學
Holistic Medicine Gordon JS, Am J Orthopsychiatry, 1990 它著重於spiritual dimension以擴展 biopsycho-social model 認知每一個病人的獨特性、治療伙伴為軸心、首重自我照顧 Gordon JS, Am J Orthopsychiatry, 1990
Holistic Medicine The simple consciousness-based, holistic medicine： 給予愛和勝利的信任 給予支撐 獲得准許去幫助病人感受、明白及去除負面的信念 Holistic medicine 不是神蹟治癒，而是具有同理心的醫師教導病人用「勤奮而守紀律的態度」來自我影響，以支持病人改善未來生活品質、健康和身體功能 VentegodtS, et al. ScientificWorldJournal2004
Holistic Medicine Ventegodtet al. ScientificWorld Journal 2004 Biomedicine 著重身體的生物化學 Biomedicine 以個體的分子為導向 Consciousness-based medicine--holistic medicine 著重個體的經驗和意識 Consciousness-based medicine 以個體的整體為導向 Ventegodtet al. ScientificWorld Journal 2004
Holistic Medicine & Care/Approach 有多種定義 全部醫學、全包醫學、全體醫學 含complementary, alternative, or integrative medicine (CAIM) 但卻不是「全人醫療」 有多種定義 全部醫學的照顧 可含complementary, alternative, or integrative medicine (CAIM) 全人照顧 使用此一名稱時要先予以定義
What Is CAM? Nonclinical self-care and lifestyle practices Acupuncture Massage Yoga Tai chi chuan Ayurvedic care Diet Exercise Spiritual healing Acupuncture Homeopathy Herbal medicine Relaxation therapies Well-established disciplines Chiropractic therapy Osteopathy Dr. Benner: Please also mention vitamins. 17
National Center for Complementary and Alternative Medicine (NCCAM) CAIM的七大分類 Alternative systems of medical practice (e.g., Ayurvedic, Traditional Chinese Medicine) Mind-body interventions (e.g., guided imagery, support groups, meditation, yoga, prayer) Manual healing (e.g., massage, chiropractic, therapeutic or healing touch) Pharmacologic and biologic treatments (e.g., shark cartilage, megavitamins) Bioelectromagnetic applications (magnets) Herbal medicine Diet, nutrition, and lifestyle changes
Conventional vs CAM 傳統西方醫學 另類替代醫學 Aim to eradicate the cause +/- reverse process New therapies introduced via double-blind RCTs Endpoints: morbidity, mortality, surrogate markers that reflect known cause and natural history 另類替代醫學 Aim to improve patient’s feelings of well being Some modalities not easily evaluated in classic double-blind, RCT format To correct the disturbance in health that affects how the patient interacts with family and environment
Epidemiology of CAM Prevalence of the use of complementary and alternative medicine (CAM) in US adults 1990 2.5% 1997 12.1% 2002 18.9% 1999 Estimated sales >$3 billion in the US Worldwide, underdeveloped countries Europe Regulate herbs as prescription or nonprescription medicines available only through a pharmacist German physicians receive medical school training in medicinal herbs (and must pass a test to become licensed) As many as 65% of US population reported to use “unconventional therapies” Europe - Except Netherlands and UK 20 20
以病人為中心的醫療服務 以醫師為中心 - 全院醫療 以病人為中心 - 全人醫療
全人醫療—薛亞聖副教授 對病人的照護達到深度與廣度、預防與治療兼顧的境界，用最經濟有效的方法促進個人健康。 縱向—對生命週期中之生、老、病、死等過程作持續性照顧。 橫向—包含身、心、靈以及家庭等各層面的完整性照顧。
賴其萬教授 醫生在他們的工作裡發現什麼樣的意義？ 有意義的經驗裡似乎可以找到一個共同點，那就是透過這經驗，他們跨出自我的藩籬，發現自己不再只是一個冷眼旁觀用科學態度來對待疾病的觀察者、開藥的人、或是安排檢查的人。 醫生們發覺到最感到安慰的是「他們的存在產生了治療的效果」。…融入病人世界裡，以彼此間的「人性」做為共同的出發點 賴其萬教授
Professional Guidelines Socio-cultural Values Holistic Health Care Professional Guidelines Socio-cultural Values Doctor’s View Patient’s View Family’s View Law Economical Issues 陳建宇 醫師
全人醫療的定義 Whole person medical care Medical care for the whole person Biopsychosocial aspects Spiritual dimension? Evidence-based
課程大綱 何謂全人醫療？ 全人醫療在專科的運用 全人醫療與六大核心能力
The ‘Branding’ of Emergency Medicine Presidential Keynote Address Prof. Dr Abu Hassan Asaari Abdullah “ Holistic and Quality Care”
ED “holistic” care It is defined as the practice of Emergency Medicine that embraces ‘total patient care’ in principle and philosophy. The care should extend in terms of emotional, physical, mental and spiritual needs of patients
ED “Quality Care” This incorporates the best arts and sciences of initiating medical management in the Emergency practice. Structures, resources and systems are built and formulated for best comfort and care for patients. Best evidences and practices are used in providing 1st class medical treatment in emergent needs.
全人醫療夢幻急診 1 A pre-hospital care service that could reach people at a reasonable timing and efficiently transport the right people to the right place with the right time. ‘smiling faces’ waiting at the triage counter and caring doctors managing each and every patient. Reasonable waiting time for non-critical patients or great wait management system.
全人醫療夢幻急診 2 Zero missed or misdiagnosis and zero complaints - zero defect medicine Good complaint management system The practitioners too should always be ready for any disaster or mass casualty incidences. 1st Class resuscitation for collapsed patients.
全人醫療夢幻急診 3 Widespread evidence-based practice, up-to-date knowledge of initiation of immediate medical management and stabilization for all diseases and injury. Produce world-class products of research and development which improves patient care significantly.
急診全人醫療的重要 EM will be placed at a great pedestal in the eyes of both medical fraternity and people . EM is a critical success factor for a complete total healthcare system. A holistic approach which embraces total quality care is the way forward for a good medical system.
回到急診現實狀況 360° feedback for EP in Singapore Emerg Med J 2007;24:574–575
全人醫療原則 Above All, Do No Harm Treat the Whole Person Respect the Healing Power of the Patient Empower the Patient Emphasize Prevention Provide Culturally Competent Care NURSING CLINICS OF NORTH AMERICA 2002;37(1):123-33
課程大綱 何謂全人醫療？ 全人醫療在專科的運用 全人醫療與六大核心能力
六大核心能力與全人醫療 生理 心理 社會 Patient Care Medical Knowledge Practice-Based Learning Interpersonal Skills Professionalism Systems-Based Practice 生理 心理 社會
人際關係與溝通技巧 人際關係 溝通技巧 跨部門和醫療同仁的關係 部門內的關係，團隊合作和合作技能 病人及家屬的照護經驗 抱怨處理和服務補救 衝突管理 危機資源管理 告知壞消息 顧及多元文化的醫病溝通 談判技巧
體制下的臨床工作 臨床資訊系統 電腦醫囑 臨床決策支援 電子病歷 醫療資訊整合 急診管理 契約與執業模式 病人流量和處理速度 財務原則 人力資源管理
體制下的臨床工作 急診運作 政策與流程 急診資料搜集與營運指標 急診安全,保全與暴力 健康照護整合 臨終與安寧照護 長期照護 門診服務
體制下的臨床工作 規定/法律 醫院評鑑及緊急醫療能力分級評定 合乎法規與報告要求 病人隱私 知情同意,照護容量和拒絕治療 緊急醫療救護法 外部品質指標 風險管理 法律責任和訴訟 醫療責任保險 減少風險 健康照護的發展趨勢 區域化的緊急醫療照護
在雲林難忘的一夜-江文莒醫師 我於是說：『要不然你們就簽自動出院吧，有事我們不負責 ! 』。 想不到一直不說話的溫先生竟然開口道：『簽就簽吧!反正我爛命一條。』 可是他接下來的話卻讓我啞口無言：『我們可以讓病人因病而死，卻不能讓病人因貧而死!』 我懊惱驚覺：『當我擁有愈多時，我願意給的竟然愈少!』