臨牀透析 Vol.34 No.2(11)


特集名 透析患者のリハビリテーション―訓練と支援
題名 地域完結型医療の現状と課題
発刊年月 2018年 02月
著者 原田 孝司 長崎腎病院
著者 佐々木 修 長崎腎病院
著者 一ノ瀬 浩 長崎腎病院
著者 橋口 純一郎 長崎腎病院
著者 舩越 哲 長崎腎病院
【 要旨 】 透析患者の高齢化に伴い,在宅療養のための多職種が関わった地域完結型医療が必要である.高齢透析患者では要支援・要介護患者が増加し,療養環境はさまざまである.在宅療養のためには地域包括ケアネットワークの整備が必要である.地域によっては,在宅Dr.ネットを結成し,患者の居住地域の主治医を決め,副主治医との連携で訪問診療や緊急対応を行っている.人生最終段階における医療として,意思決定プロセスに従った事前指示書の提出による患者の意思を尊重した医療を行う必要がある.
Theme Rehabilitation therapy in dialysis patients -- training and support
Title The present situation of and issues in regional comprehensive care network
Author Takashi Harada Nagasaki Kidney Hospital
Author Osamu Sasaki Nagasaki Kidney Hospital
Author Hiroshi Ichinose Nagasaki Kidney Hospital
Author Junichiro Hashiguchi Nagasaki Kidney Hospital
Author Satoshi Funakoshi Nagasaki Kidney Hospital
[ Summary ] In order to realize home healthcare, a regional comprehensive care network involving multiple occupations is necessary. Due to the aging of dialysis patients, the number of patients who require support/long-term nursing care is increasing, and the medical care environment varies. In order to realize home care, it is necessary to develop a regionally-contained healthcare system. Depending on the region, a home doctor network is established, the physician in charge of the residential area of the patients is deployed and the home visit medical treatment and emergency response functions are performed in cooperation with the assistant attending physician. In case of patients at the end-of-life stage, it is necessary to conduct medical treatment that respects their intentions by submitting in advance, written instructions according to the decision-making process.
戻る