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​科研及知識轉移項目

近年已有多項研究及健康推廣項目証實預設照顧計劃 (Advance Care Planning, ACP) 在華人社區中的可行性及接受度。這些項目都賦權大眾理解日後可能面對治療及照顧方案，而項目的評估結果亦反映了 ACP 對個人、家庭及社會都帶來正面的影響。

「讓我說說」預設照顧計劃項目

"Let Me Talk" ACP programme

首套為華人文化設計的預設照顧計劃方案。自2005 年起，於香港的安老院舍為長者進行預設照顧計劃，以故事方式 (storytelling) 引導他們：

  • 【我的故事】：回顧人生經歷

  • 【我的看法】：從而讓他們釐清自己對生命的看法

  • 【我的意願】：及為生命最後一程進行規劃

 

及後，這方式也陸續於國內及其他亞太地區應用或作為參照。

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「智友SAY」

"Have a Say" ACP Programme

於「讓我說說」項目的框架之下，延伸理念至患有初期認知障礙症人士及家屬，不單只關注晚期照顧，亦涵蓋長期照顧的需要，讓他們未雨綢繆。

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計劃過程讓他們預先了解病症可能帶來的影響，及趁患者仍有思考能力時，及早與家人討論自己對日後照顧的想法，避免家庭於代作照顧決定時出現意見分歧。

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​「吾可預計」預設照顧計劃項目

"My Way" ACP Community Campaign

「吾可預計」項目主要是於社區推廣預設照顧計劃。名稱之靈感來源於與計劃過程中，很多人都感慨「將來的事都『唔』可預計」，代表不可預計。項目將「唔」變作意為「我」的「吾」，將否定變為肯定，強調對個人照顧的掌握，賦權予每個人可在妥為知情下決定如何為自己規劃日後的照顧。

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「我的護照」

「我的護理照顧計劃」項目

這項目是「吾可預計」的延伸，將預設照顧計劃的理念在基層醫療作推廣，對象不再只針對長者、末期或長期病患者，讓更多人了解如何可為自己或親友籌劃晚期照顧。

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項目亦包括為醫護及社福界同工提供預設照顧計劃的培訓，讓他們能更有信心去開啟相關話題，及推動服務發展。

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預設照顧計劃工具

為醫療照顧作出決定並不容易，因為當中牽涉很多醫療、社福及法律知識，要展望未來時的照顧就更是複雜。為了幫助公眾了解各種照護選項的優缺點，本地已開發了多種教育及資訊工具，包括微電影、桌遊和沉浸式虛擬實境影片，讓大家可更具體認識各選項內容。

​微電影

電影是基於臨床常見的情況拍攝，故事反映家庭成員為病重患者代作照護決策時所臨的內心掙扎與矛盾，讓觀眾明白預設照顧計劃不僅關乎個人福祉，也關係到整個家庭的和諧及心理負擔。期望可透過電影情節，讓更多人明白及早計劃的重要性，從而減輕家人未來面臨的選擇壓力。

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​吾可預計之守望

桌上遊戲

「五味雜貨店」是首個共同設計於華人社區用作生命教育的棋盤遊戲。該項目由香港中文大學醫學院那打素護理學院與東華三院共同主導研發，並以實證支持，顯示遊戲過程可讓玩家積極反思自己對生死的觀點，而當中的交流亦可讓玩家了解他人對於晚期照顧的看法。

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沉浸式影片

​很多人都對晚期照顧感到陌生，所以難以明白預設照顧計劃的重要性。因此，香港中文大學醫學院那打素護理學院團隊拍攝了一段沉浸式影片，以病人第一身視角呈現病人沒法參與自己的治療決策時的情況，作教學用途，期望可提升醫護學生對病人的同理心。評估反映影片讓學生反思溝通態度及治療對病患者身心的影響。

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​相關文獻

​以上項目亦經已在多份國際醫學及護理雜誌上發表，下列為其中主要作品：

​各類ACP介入方式之效用

​溝通模式

  • Chan, H. Y. L., Leung, D. Y., Lam, P. T., Ko, P. P., Lam, R. W., & Chan, K. S. (2025). Effect of motivational interviewing to promote advance care planning among palliative care patients in ambulatory care setting: a randomized controlled trial. BMC Palliative Care, 24(1), 72. https://doi.org/10.1186/s12904-025-01692-8

  • Leung, D. Y. P., Chung, J. O. K., Chan, H. Y. L., Lo, R. S. K., Li, J., Lam, P. T., Ng, N. H. Y. (2024). Effects of a structured, family-supported, and patient-centred advance care planning on end-of-life decision making among palliative care patients and their family members: Protocol of a randomised controlled trial. BMC Palliative Care, https://doi.org/10.1186/s12904-024-01588-z

  • ​Lai J. C. T., Chan, H. Y. L. (2022). A video decision aid for advance care planning among community-dwelling older Chinese adults: A cluster randomized controlled trial. Journal of Palliative Medicine. http://doi.org/10.1089/jpm.2022.0269

  • Deng, R., Zhang, J., Chen, L., Miao, J., Duan, J., Qiu, Y., Leung, D., Chan, H. Y. L., & Lee, D. T. (2020). The effectiveness of a modified advance care planning programme. Nursing Ethics, 27(7). 1569-1586. doi: 10.1177/0969733020922893

  • ​Leung, D.Y.P., Chan, H. Y. L., Yau, S.Z.M., Chiu, P.K.C., Tang, F.W.K.., Kwan, J.S.K. (2019). A video-supported nurse-led advance care planning on end-of-life decision making among frail geriatric patients: Protocol for a randomized controlled trial. Journal of Advanced Nursing, 75(6), 1360-1369. https://doi.org/10.1111/jan.13959

  • ​Chan, H. Y. L., Ng, J.S.C., Chan, K.S., Chan, L.N., Ko, P.S., Leung, D.Y.P., Lee, I.F.K., Lee, D.T.F., Chan, C.W.H. (2018). Effects of a nurse-led post-discharge advance care planning programme for community-dwelling patients nearing the end of life and their family members: A randomised controlled trial. International Journal of Nursing Studies, 87, 26-33.

  • Ng, A. M. F., Leung, D. Y. P., Chan, H. Y. L. (2015). Effects of advance care planning on knowledge, behaviour, and well-being of older adults: A systematic review. Asian Journal of Gerontology and Geriatrics, 10.

  • Chan, H. Y. L. & Pang, S. M. C. (2010). Let Me Talk – an advance care planning programme for frail nursing home residents. Journal of Clinical Nursing, 19, 3073-3084.

遊戲方式

  • Liu, L., Chan, H. Y. L., Zhao, Y. Y., Xiong, G. J., Qing, M. B., Gu, C., & Wang, Y. (2025). Effects of a Game on Advance Care Planning Engagement in Older Adults: A Randomised Controlled Trial. Journal of Pain and Symptom Management.  https://doi.org/10.1016/j.jpainsymman.2025.02.016

  • Liu, L., Wang, Y., Ho, T. C., Li, M. M., Cheung, E. W., Chow, R. S., Gu, C., & Chan, H. Y. L. (2024). Co-designing a Culturally-Sensitive Theory-Driven Advance Care Planning Game with Chinese Older Adults and Healthcare Providers. Palliative Medicine. https://doi.org/10.1177/02692163231222776

  • Liu, L., Chan, H. Y., Ho, T. C., Chow, R. S., Li, M. M., Cheung, E. W., Gu, C., & Wang, Y. (2023). A serious game for engaging older adults in end-of-life care discussion: A mixed method study. Patient Education and Counseling, 113, 107787. https://doi.org/10.1016/j.pec.2023.107787

  • Liu, L., Zhao, Y.Y., Yang, C., & Chan, H. Y. L. (2021). Gamification for promoting advance care planning: A mixed-method systematic review and meta-analysis. Palliative Medicine, 35(6), 1005-1009.

​認知障礙症人士

  • Yeung, C. Y., & Chan, H. Y. L. (2025). Promoting advance care planning in people with early dementia and their family caregivers. Hong Kong Medical Journal, 31 S3(3), 23–26

  • Yeung, C. C. Y., Ho, K. H. M., & Chan, H. Y. L. (2023). A dyadic advance care planning intervention for people with early-stage dementia and their family caregivers in a community care setting: A feasibility trial. BMC Geriatrics, https://doi.org/10.1186/s12877-023-03815-3

​有關ACP評估工具

專業準備度

  • Yuen, J. K., Chan, H. Y. L., Chen, T. W. T., Chu, S. T., Kwok, A. O. L., Leung, D. Y. P., Gill, H. S., Tsang, K. W., Tse, D. M. W., Yap, D. Y. H., Yip, T., & Arnold, R. M. (2025). Cross-cultural adaptation and validation of the Chinese version of the quality of communication questionnaire. BMC Palliative Care, 24(1), 140. https://doi.org/10.1186/s12904-025-01786-3

  • ​Chan H. Y. L., Chun GKM, Man CW, Leung EMF. (2018). Staff preparedness for providing palliative and end-of-life care in long-term care homes: Instrument development and validation. Geriatric and Gerontology International, 18(5), 745-749.

​公眾準備度

  • ​Liu, L., Zhao, Y.Y., Zhang, L.H., Chan, H. Y. L. (2020). Measuring self-efficacy and readiness for advance care planning in Chinese older adults. Journal of Pain and Symptom Management, 60(3):622-629. doi: 10.1016/j.jpainsymman.2020.06.013​

​有關ACP培訓

  • Chan, C. W. H., Ng, N. H. Y., Chan, H. Y. L., Choi, K. C., Chow, K. M., Kwan, C. W. M., Robinson, J., & Tse, M. (2025). The effects of a Multi-media Experiential Advance Care Planning (MEACP) training programme for nurses in the acute care settings: A cluster randomised controlled trial. Nurse Education in Practice, 86, https://doi.org/10.1016/j.nepr.2025.104428

  • Chan, C. W., Ng, N. H., Chan, H. Y., Choi, K. C., Chow, K. M., Kwan, C. W., Robinson, J., & Tse, M. (2025). Development and pilot testing of a theory-driven and evidence-based advance care planning training programme for nurses in acute care settings. European Journal of Oncology Nursing, 74, https://doi.org/10.1016/j.ejon.2024.102760

  • Chan, H. Y. L., Kwok, A.O.L., Yuen, K.K., Au, D. K.S., Yuen, J.K.Y. (2020). Association between training experience and readiness for advance care planning among healthcare professionals: A cross sectional study. BMC Medical Education. https://doi.org/10.1186/s12909-020-02347-3

  • Chan, C.W.H., Ng, N.H.Y., Chan, H. Y. L. et al. (2019). A systematic review of the effects of advance care planning facilitators training programs. BMC Health Service and Research, 19, 362. https://doi.org/10.1186/s12913-019-4192

​影響ACP推行之因素

  • Mori, M., Chan, H. Y. L., Lin, C. P., Kim, S. H., Ng Han Lip, R., Martina, D., Yuen, K. K., Cheng, S. Y., Takenouchi, S., Suh, S. Y., Menon, S., Kim, J., Chen, P. J., Iwata, F., Tashiro, S., Kwok, O. L. A., Peng, J. K., Huang, H. L., Morita, T., Korfage, I. J., … Kizawa, Y. (2024). Definition and recommendations of advance care planning: A Delphi study in five Asian sectors. Palliative medicine, 2692163241284088. Advance online publication. https://doi.org/10.1177/02692163241284088

  • Lin, C. P., Peng, J.K., Hsieh, W.T., Martina, D., Mori, M., Takenouchi, S., Chan, H.Y.L., Suh, S.Y., Kim, S.H., Yuen, K.K., Kizawa, Y., Cheng, S.Y. (2023). Improving Access to Advance Care Planning in Current and Future Public Health Emergencies: International Challenges and Recommendations. Journal of Palliative Medicine, 26(4), 462-463.http://doi.org/10.1089/jpm.2023.0030

  • Chan, C. W. H., Chen, Y. F., & Chan, H. Y. L. (2023). Advance Care Planning in Hong Kong. Zeitschrift fur Evidenz, Fortbildung und Qualitat im Gesundheitswesen, 180, 90–93. https://doi.org/10.1016/j.zefq.2023.05.015

  • Cheng, S. Y., Lin, C.P., Chan, H. Y. L., Martina, D., Mori, M., Kim, S., Ng, R. (2020). Advance care planning in Asian culture. Japanese Journal of Clinical Oncology, 50(9), 976-989. doi.org/10.1093/jjco/hyaa131

  • Chan, H. Y. L., Lee, D.T.F., Woo, J. (2020). Diagnosing gaps in the development of palliative and end-of-life care: A qualitative exploratory study. International Journal of Environmental Research and Public Health, 17, 151, doi: 10.3390/ijerph17010151

  • Ngan, O.M.Y., Bergstresser, S.M., Sanip, S., Emdadul Haque, A.T.M., Chan, H. Y. L., Au, D.K.S. (2019). Cultural considerations in forgoing enteral tube-feeding: A comparison between the Hong Kong Chinese, North American, and Malaysian Islamic patients with advanced dementia at the end-of-life. Developing World Bioethics, DOI: 10.1111/dewb.12239

  • Lin, C.P., Cheng, S.Y., Mori, M., Yeon, S.S., Chan, H. Y. L. Diah, M., ..et al.(2019). Taipei Declaration on Advance Care Planning: A cultural adaptation of end of life care discussion. Journal of Palliative Medicine, 22:1175-1177

  • Woo, J., Chan, H. Y. L., Chong, A. M. L., Zou, M., Chung, R. Y., & Kwok, T. (2015). Medical Ethical Principles may Drive Improvement of Quality of Dying in Hong Kong. Journal of Palliative Care and Medicine. http://dx.doi.org/10.4172/2165-7386.1000227

  • Nan, K., Lai, R. Y. K., Chan, H. Y. L. (2022). Decision control preference for end-of-life care among older adults. Geriatrics and Gerontology International. doi: 10.1111/ggi.14540

  • Wan, Z.; Chan, H. Y. L.; Chiu, P.K.C.; Lo, R.S.K.; Cheng, H.L.; Leung, D.Y.P. (2022). Experiences of Older Adults with Frailty Not Completing an Advance Directive: A Qualitative Study of ACP Conversations. Int. J. Environ. Res. Public Health 2022, 19, 5358. https://doi.org/10.3390/ijerph19095358

  • ​Chan, C.W.H., Wong, M.M.H., Choi, K.C., Chan, H. Y. L., Chow, A.Y.M., Lo, R.S.K., Sham, M.M.K. (2019). What patients, families, health professionals and hospital volunteers told us about advance directives? Asia Pacific Journal of Oncology Nursing, 6, 72-77.

  • Chan, C.W.H., Wong, M.M.H., Choi, K.C., Chan, H. Y. L., Chow, A.Y.M., Lo, R.S.K., Sham, M.M.K. (2019). Prevalence, Perception and Predictors of Advance Directives among Hong Kong Chinese: A Population-based Survey. International Journal of Environmental Research and Public Health, 16(3), 365.

  • Chan, H. Y. L. & Pang, S. M. C. (2011). Readiness of Chinese frail old age home residents to end-of-life care decision making. Journal of Clinical Nursing, 20, 1454-1461.

  • Chan, H. Y. L. & Pang, S. M. C. (2007). Quality of life concerns and end-of-life care preferences of aged persons in long-term care facilities. Journal of Clinical Nursing, 16, 2158-2166.

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