社区安宁疗护服务对象准入准出标准研究

目的 构建上海市社区安宁疗护准入、准出标准，以指导社区筛选出真正属于安宁疗护范畴并急需照护的人群。 方法 通过文献回顾和焦点小组访谈确定出安宁疗护服务对象的准入、准出判断维度；于2017年7—8月间邀请6家上海市安宁疗护试点单位安宁疗护科资深执行人和管理者代表，经过两轮Delphi咨询，采集各位专家对社区安宁疗护准入、准出标准的意见。 结果 社区安宁疗护服务对象准入的4个判断维度分别是:病种、生存期、症状、患者和家属的主观意愿；准出的3个判断维度分别是:患者和家属的主观意愿、症状、患者死亡。居家和机构安宁疗护准入标准的差异主要体现在:病种(机构比居家多一个脑血管病)、生存期(居家倾向于<180 d，机构倾向于<90 d)、症状(机构可以处理更多的临床症状)。居家和机构安宁疗护准出标准的差异主要体现在机构准出标准需考虑临床症状缓解、生存期延长等因素。 结论 本研究梳理的社区安宁疗护准入、准出标准，与现有的安宁疗护标准相比，补充了生存期的其他要求，明确了病种范围，并综合考虑了社区安宁疗护试点单位的服务能力和服务对象意愿的表达方式，新增了准出标准，为居家安宁疗护、机构安宁疗护和综合医院间有序转介奠定了基础。 

Study on admittance and exit criteria of palliative care in community

Objective To build the admittance and exit criteria of palliative care in community, so that to guide the communities to screen people who really belong to the area of peace care and need the palliative care most. Methods Through the literature review and focus group interviews, it got the dimensions of the admittance and exit criteria for palliative care in community. Deeply, executive and managerial representatives from six pilot units of palliative care in Shanghai were invited to participate in the two rounds of Delphi consultation, which was designed to collect the opinion on the admittance and exit criteria for palliative care in community from them. Results The four dimensions of admittance criteria for palliative care in community were disease, survival, symptom, subjective intention of patients and their families. The three dimensions of exit criteria were subjective intention of patients and their families, symptom and the death of patients. Compared with the admittance criteria for palliative care at home, the palliative care in institutions showed the difference in the admittance criteria of disease, survival, and symptom. In terms of access requirements for the disease, the palliative care in institutions allowed the cerebrovascular disease while the palliative care at home did not. In terms of survival, the palliative care in institutions tended to accept patients with a survival period of less than 90 days, while the palliative care at home tended to accept patients with a survival period of less than 180 days. Conclusion Compared with the original criteria, the admittance and exit criteria of palliative care in community in this study complements the other requirements of the survival time, defines the range of the disease, and takes into account the service capacity of the pilot units and the expression of the willingness of the client. What's more, it adds the exit criteria, which could lay the foundation for the orderly referral among the palliative care at home, the palliative care in institutions and general hospitals.