J Sci Discov (2017); 1(1):jsd17002; DOI:10.24262/jsd.1.1.17002; Received April 8th, 2017, Revised April 14th, 2017, Accepted April 14th, 2017, Published April 16th, 2017.
Promotion of Advance Care Planning in Taiwan
1En Chu Kong Hospital,Sanhsia District,New Taipei City, 23702, Taiwan
* Correspondence: Rong-Chi Chen, En Chu Kong Hospital,Sanhsia District,New Taipei City, 23702, Taiwan. Email: firstname.lastname@example.org.
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 the 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.
Keywords: Hospice care,Palliative care, Natural death act, Hospice palliative care act, Patient self-determination act, Advance care planning, Advance directive,Advance medical decision
Modern hospice palliative care started in 1967 by Dr. Dame Cicely Saunders’St. Christopher’s Hospice in England. . 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 . In 1993, Catholic Sanipax Socio-Medical Service & Education Foundation (Kung Tai) was found .In 1994 the Buddhist Lotus Hospice Care Foundation (Lotus Foundation) was established . 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) , Taiwan Motor Neuron Disease Association (1997) , Taiwan Academy of Hospice Palliative Medicine (1999) , Taiwan Association of Hospice Palliative Nursing (2005), Taiwan Association of Clinical Buddhist Studies (2007) .
In 1995, the Department of Health（DOH）(later promoted as Ministry of Health and Welfare, MOHW) organized a taskforce to develop hospice palliative care. 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-Determination Act (PSDA) was enacted, to be effective 3 years later (i.e. January 6, 2019). 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 the irreversible comatous state, 3. In the persistent vegetative state, 4. In the severe dementia state, 5. The patient is in intolerable pain, an 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.
Advance Care Planning
In article 3, paragraph 3 of the PSDA, 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:
- A medical institution has offered advance care planning consultation and affixed a seal to the advance medical decisions for certification purposes.
- 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.
- 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 personnel (members of the consulting team) of hospitals to participate in the consultation of advance care planning.
The guidelines for hospice care for patients with dementia  and for patients requiring renal dialysis  at the 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 the 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.”
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 Amida buddha.
The authors declare that they have no competing interests.
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