RESUMO
BACKGROUND: Motor neuron disease (MND) is a neurodegenerative disease characterized by loss of motor neurons in the spinal cord, brainstem and motor cortex. Clinically it is manifested as progressive decline in physical, respiratory, swallowing and communication function and ultimately death. Traditional model of care was fragmented and did not match with patients and carers multi-facet needs. METHODS: A special workgroup for MND patients that includes neurologist, respiratory physician, rehabilitation specialist and palliative care (PC) physician was formed in Hong Kong since year 2013. In various disease phase, each specialty team play a leading role in coordinated care of MND patients. RESULTS: From Apr 2013 to Mar 2015, 41 patients newly diagnosed with MND were cared in our model. 96.4% agreed to participate in the ACP discussion. Seventy-five percent of them opted for do-not-attempt cardiopulmonary resuscitation (DNACPR) and no intubation/mechanical ventilation. There were 16 (51.6%) of patients passed away within the review period. All of them succumbed with no CPR performed which was honoring their wish. The average duration under PC was 118 days. CONCLUSIONS: Strategies toward standardizing care delivery for MND patients and carers may help to address the physical, psychosocial and spiritual needs of MND patients. The experience shared from this article conceptualizes the roles of various multi-disciplinary team members, with emphasis paid on PC team position in taking care of advanced MND patients.
