Promotion of Advance Care
Planning in Taiwan
Rong-Chi Chen, MD, PhD, FANA1
1En Chu Kong Hospital,Sanhsia
District,New Taipei City, 23702, Taiwan
#Chen RC. (2017).
Promotion of advance care planning in Taiwan.
J Sci Discov
(2017); 1(1):jsd17002; DOI:10.24262/jsd.1.1.17002;
Abstract
Hospice
palliative care started in Taiwan in 1990. Foundations of Christian, Catholic
and Buddhist background and associations with medical, nursing and various
social background joined in promotion of this
modern humanistic medical care. Hospice Palliative Care Act (a Natural
Death Act) was enacted in 2000 and Patient Self-Determination Act passed in
2016 to be effective in January 2019. Taiwan is engaged in preparation for
advance care planning consultation to facilitate the implementation of this new
law and further promotion of the quality of hospice palliative care.
Key Words: Hospice care,Palliative care, Natural death act,
Hospice palliative care act, Patient self-determination act, Advance care
planning, Advance directive,Advance medical decision
Introduction
Modern hospice palliative care started in
1967 by Dr. Dame Cicely Saunders’St. Christopher's Hospice in England. [1]. This humane
form of holistic health care has gradually spread around the world, reaching
Taiwan in 1990. [2,3]. In 1990 a Christian Hospice Foundation of Taiwan was established [4]. In 1993 Catholic Sanipax
Socio-Medical Service & Education Foundation (Kung Tai) was found [5].In 1994 the Buddhist Lotus Hospice Care Foundation
(Lotus Foundation) was established [6]. The cooperation of these 3 religious
organizations became the major momentum of Taiwan’s hospice movement.These were
followed by the establishment of several non-profit-organizations (NGO) for the
promotion of hospice palliative care : Taiwan Hospice Organization (1995) [7], Taiwan Motor Neuron Disease Association (1997)
[8], Taiwan Academy of Hospice Palliative Medicine (1999) [9], Taiwan Association of Hospice Palliative Nursing (2005)[10], Taiwan Association of Clinical Buddhist Studies (2007) [11].
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Governmental support
In 1995, the Department of Health（DOH）(later
promoted as Ministry of Health and Welfare, MOHW) organized a taskforce to
develop hospice palliative care.[12] Since 1996,
the National Health Insurance（NHI） started funding of the hospice home care,
then in-patient hospice care.
Gradually, hospice palliative care was also encouraged
and required by the Taiwan Joint Commission on Hospital Accreditation. Besides
terminal cancer patients, in 2009, the NHI started funding of hospice care for
terminal patients suffering from all major organ failures (such as brain,
heart, lung, liver or kidney failures). Patients suffering from amyotrophic
lateral sclerosis and AIDS were also covered.
Hospice Palliative Care Act (Natural Death Act)
In 2000, Taiwan’s Natural Death Act was
passed with the name “Hospice Palliative Care Act”[13,14]. This Act gives our people the right to write a letter of intent for the
choice of hospice palliative care (HPC) or life sustaining treatment (LST) at
the terminal stage of life. Thus our people have the legal right to withhold
cardiopulmonary resuscitation (CPR), i.e. to choose do-no-resuscitation (DNR) and the right to
withdraw futile CPR, such as withdrawal of mechanical ventilator. This letter
of intent can be written in the National Health Insurance certificate (NHI card)
which can be read when a patient receives medical care.
Patient Self-Determination Act
In January 2016, the Patient Self-Deterrmination
Act (PSDA) was enacted, to be effective 3 years later (i.e. January 6, 2019)[15].
In Article 3 of this Act, the Life Sustaining Treatment (LST) is defined as the
following measures: “Any medical and nursing measures which can prolong the
life such as cardiopulmonary resuscitation (CPR), artificial ventilation,
mechanical life sustaining system (such as ECMO), blood substitutes, special
treatment for specific diseases, for example, chemotherapy, dialysis,
antibiotics for fatal infections, artificial nutrition and artificial liquid
feeding, etc.” In Article 14,” the patient can ask for withholding or
withdrawal of whole or part of the life sustaining treatments if he/she is 1. A
terminal patient, 2. In irreversible comatous state, 3. In persistent
vegetative state, 4. In severe dementic state, 5. Patient is in intolerable
pain, incurable disease without adequate solution under the current medical
standard.” The above items must be confirmed by 2 specialists and Item 5 must
be confirmed by consultation with hospice team[16].
Advance Care Planning
In article 3, paragraph 3 of the PSDA[15], Advance medical decision(AMD) or advance directive (AD)is defined as “to
a previously made written statement that explicitly expresses a person’s wishes
and decisions to receive or refuse life-preserving treatments, artificial
nutrition and hydration or other measures related to medical care and a good
death when the person is in specific clinical conditions.”
In article 3, paragraph 6, Advance care
planning (ACP) is defined as “to the process of communication between the patient and medical service providers,
relatives and other relevant personnel regarding the proper care that shall be
offered to the patient and the patient’s consent to or refusal of
life-preserving treatments and artificial nutrition and hydration when the
patient is in specific clinical conditions, unconscious or unable to clearly
express his or her wishes.”
Article 9 (Procedural requirements for
advance medical decisions):
“The advance medical decisions of a will
maker shall conform to the following provisions:
1. A medical institution has offered advance care
planning consultation and affixed a seal to the advance medical decisions for
certification purposes.
2. The decision has been notarized by a notary
public or is made in the presence and under the witness of two or more persons
with full disposing capacity.
3. The decision has been registered on the
national health insurance card.
The will maker, at least one relative within
the second degree of affinity and the medical surrogate shall participate in
the advance care planning consultation set forth in Subparagraph 1 of the
preceding paragraph. Relatives who have obtained consent from the will maker
may also participate in the advance care planning .
If
there is a fact sufficient for the medical institution that has offered the
advance care planning consultation set forth in Subparagraph 1 of Paragraph 1
to deem that the will maker is mentally deficient or has not made the decision
of his or her own free will, it shall not affix a seal for certification
purposes.
The medical surrogate of the will maker,
members of the responsible medical care team and persons specified in all of
the subparagraphs of Paragraph 2 of Article 10 must not serve as the witnesses
set forth in Subparagraph 2 of Paragraph 1.
The regulations governing the qualifications
of the medical institution that offers advance care planning consultation,
members of the consulting team that it shall form and their eligibility,
relevant procedures and other matters to be complied with shall be enacted by
the central competent authority.(i.e.MOHW)”
In order to follow the requirements of the
PSDA,the Ministry of Health and Welfare (MOHW) has promoted relevant medical
societies and specialists in care of the medical conditions cited in article
14, and all levels of hospitals to participate in different symposia or
education courses for training personells (members of the consulting team) of
hospitals to participate for the consultation of advace care planning.
The guidelines for hospice care for patients
with dementia [17] and for patients requiring renal dialysis [18] at terminal stage of life were established
as required by the PSDA. Hope in the following 2 years guidelines for advance
care planning for many terminal or incurable diseases with intolerable pain
will be established.
Although we are not satisfied with our current
care quality, the international survey of the quality of death and also quality
of palliative care by the Lien Foundation ranked Taiwan as the 14th/40 in the
world in 2010 and 6th/80 in 2015. Taiwan ranked the first in Asian Countries in
both times[19-20]. We will continue to improve our quality of care and coverage of hospice
care in Taiwan.
In promotion of the concept of hospice
care we tried to educate the public, “Filial
duty and love should find its expression in being with the family member at the
end of his/her life, and in encouraging acceptance of disease, quiet life in
his last days and peaceful passing.”and to educate the physicians, “Where it is
unavoidable, the death of a patient is not a medical failure. Not being able to
facilitate a peaceful and dignified demise is, however.”[3]
May all the sentient beings of the world
have a good life and peaceful departure of this life and smooth travel to a new
life in the heavenly kingdom of God or pure land paradise of Amitabuddha.
References
2. Lai YL, Su WH. Palliative medicine and the
hospice movement in Taiwan. Support Care Cancer 1997; 5:348-350.
3. Chen RC Medical personnel should actively
promote the concept of terminal DNR. Tzu Chi Med J 2006; 8:155-157.
18.Hung KY, Huang CW, Tsai HB.(eds) Guidelines for Hospice Palliative Care in Terminal
Renal Disease. 2017.
Taipei: National Taiwan University Hospital.
19.Lien Foundation. The quality of death, Ranking
end-of-life care across the world. Economist Intelligence Unit, The Economist.2010; 1-36.
20.Lien Foundation.(2015). The 2015 quality of death index,
Ranking palliative care across the world. Economist Intelligence Unit, The Economist.2015;1-71.
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