背景：台灣慢性腎衰竭盛行率及發生率居全球之冠，透析治療使病人的存活期延長，但多重共病症影響生活品質。門診末期腎病接受血液透析病人必須承受共病症的折磨及面對死亡的不確定性，預立醫療自主計畫讓病人有機會去思考並表達對未來的末期照護期望。目的：本專案旨在提升門診末期腎病接受血液透析病人預立醫療自主計畫的表達率由 4.8%提升至 20%。解決方案：檢視單位 2016 年 ACP 意向表達率 4.8%，深入探討原因，經現況調查及特性要因圖分析原因為病人對 ACP 認知不足、病人的禁忌話題、缺乏 ACP 標準作業流程、缺乏 ACP 輔助溝通教材，採取六項措施，包括執行 ACP 作業流程、舉辦座談會、張貼 ACP 海報、播放 ACP 宣導短片、使用 ACP 手冊討論與填寫並張貼ACP 辨識提醒圖示。結果：ACP 意向表達率由 4.8%提升至 54.4%，附加效益：預立安寧緩和醫療暨維生醫療抉擇意願書的簽署率由 4.8%提升至 21.6%。結論：末期腎病病人有權選擇將來想要的醫療照護方式，ACP 是開始規劃未來醫療照護決策的最佳方式。本專案透過六項措施，提升病人認知，提升意向表達率及簽署率，ACP 的過程提供病人及家屬做醫療決定的依據，使病人生命末期得到合乎期待的治療與照護，提升末期照護品質，避免過多的無效醫療。

Background: Taiwan currently has the highest incidence and prevalence of chronic renal disease in the world. Dialysis is the therapeutic way to prolong life span but comorbidity may deteriorate the quality of life. Hemodialysis patients must endure comorbidities and face the uncertainties of death. The advance care planning (ACP) gives patient a chance to think and share their wishes for future health and personal care. Purpose: our aim is to promote the intention and willingness of ACP among hemodialysis patients in Taiwan. The intention expression rate of ACP among patients from the institutions surveyed in the study was 4.8% in 2016. Methods: Few patients know about ACP in Taiwan. Reasons were analyzed by conducting a survey and plotting a cause & effect diagram. We constructed six strategies of operation, including the establishment of ACP standard of operation, patient’s education forum, ACP posters and ACP video, providing ACP handbook regarding hospice care and advance directives to hemodialysis patients. Results: The intention expression rate of ACP increased from 4.8% to 54.4% and the signing rate was increased from 4.8% before to 21.6% after the intervention period. Conclusion: Patients with ESRD should have the right to decide the way medical care is provided in future. ACP is part of good healthcare, and is the best way to begin planning for future healthcare decisions. In this study, we used the six strategies to promote the intension expression of ACP on hemodialysis patients in Taiwan. Our results showed that these strategies were able to significantly increase the intention rate and signing rate. Continuous education of patients should improve the acceptance of ACP among dialysis patients and healthcare communities. By signing ACP, not only patient’s willingness for future medical care may be respected but also could avoid excess futile medical care.