医患共同决策

在新的医学模式下, 单纯以医生为主导已不能适应现代医疗环境下的医疗服务。医患共同决策(shared decision making, SDM)的内涵是医生运用专业知识, 与患者在充分讨论治疗选择、获益与损伤等各种可能的情况下, 并考虑到患者的价值观、倾向性及处境后, 由医生与患者共同参与作出的、最适合患者个体的健康决策过程。本文就SDM的历史沿革、提倡SDM的原因、患者对SDM的需求与视角、如何在医疗实践中实施SDM进行阐述, 启示临床医生一方面需具备现代医学知识与技能, 如循证医学的方法以获得最佳临床证据; 同时还需具备以患者为中心的沟通技能, 与患者建立和谐、信任的医患关系, 了解患者对治疗的偏好, 在此基础上进行SDM, 从而达到最佳医疗照护。     

我国医患共同决策的研究现状

医疗环境的改变,全民健康需求的多样化要求我们对传统诊疗模式做出调整和完善。本文从医患共同决策在我国大陆地区的临床研究现状及存在问题两方面进行综述,旨在为临床研究的实施和诊疗模式改进提供参考。     

医患共同决策相关研究文献的可视化分析

目的:探索医患共同决策领域的研究现状,剖析其研究热点和研究前沿,为相关科研工作提供思路以及辅助临床实践提供理论基础。方法:通过Web of Science文献数据库检索2008年1月1日—2022年12月31日医患共同决策相关文献,应用文献计量学的研究方法,使用R语言平台软件Bibliometrix和Java语言平台软件VOSviewer平台对文献的年发表量、国家、期刊、作者、研究机构、关键词等进行提取分析及可视化展示,分析医患共同决策研究领域的热点及发展动态。结果:共筛选纳入文献9 936篇。2008—2022年医患共同决策领域研究发文量呈现稳步增长,其中发文量排名较前的国家有美国、英国以及瑞士等。关键词热点显示医患共同决策质量和生活质量越来越受到重视,有关医患共同决策的热点研究方向主要集中在“医患共同决策”“医患交流”“医疗决策”以及“定量研究”等。结论:通过文献计量学的分析,国内外研究对医患共同决策状的热度持续增加,可以直观清晰地了解到全球针对医患共同决策领域的热点和研究前沿,为进一步进行此领域的科研工作提供基础。总体而言,医患共同决策对于提高医疗质量、增加医患互信、改善病人治疗...     

《2021 NICE医患共同决策指南》要点解读

医患共同决策对于明确患者意愿和偏好、减少患者决策后悔和决策冲突、提高患者生存质量意义重大,但目前我国对于共同决策的研究探索仍处于起步阶段。2021年6月英国国家卫生与临床优化研究所（NICE）发布了《2021 NICE医患共同决策指南》。本指南从组织政策、实践准备、决策支持工具、沟通技巧、共同决策领域目前的实施困境等方...     

慢性病患者参与医患共同决策影响因素的Meta分析

目的 对慢性病患者参与医患共同决策的影响因素进行Meta分析,为提高慢性病患者共同决策参与率提供科学依据。方法 系统检索中国知网、维普、万方、PubMed和Web of Science中英文数据库公开发表的有关慢性病患者参与医患共同决策影响因素的文献,利用Review Manager 5.4和Stata 13.0软件进行效应量合并。结果 共检索到700篇文献,根据纳排标准,最终纳入17篇中英文文献。结果显示慢性病患者医患共同决策合并参与率为36.90%(28.80%～45.00%);年龄（OR=0.92,95%CI:0.82～0.99）、文化程度（OR=1.57,95%CI:1.24～1.99）、家庭人均月收入（OR=1.60,95%CI:1.12～2.28）、是否首次手术（OR=1.85,95%CI:1.27～2.70）、疾病相关知识了解（OR=0.98,95%CI:0.96～0.99）是影响慢性病患者参与共同决策的重要因素。结论 慢性病患者医患共同决策参与率有待进一步提高,慢性病患者参与医患共同决策受多种因素影响,应对医患双方采取相应措施来提高共同决策参与率。     

医患共同决策干预在精神分裂症伴持续性幻听患者中的应用

目的:探讨医患共同决策干预在精神分裂症伴持续性幻听患者中的应用效果。方法:选取2019年1月1日~6月30日接受系统抗精神病药物治疗后住院或门诊的精神分裂症伴持续性幻听患者120例,按照随机数字表法分为观察组和对照组各60例,对照组采用常规认知行为干预护理,观察组在对照组基础上采用医患共同决策干预;比较两组治疗前后临床疗效[采用阳性及阴性症状量表(PANNS)]、幻听变化情况[采用听幻觉量表(AHRS)]及不良反应情况[采用副反应量表(TESS)],并调查患者对疾病及治疗的认知情况。结果:治疗第8周,两组PANNS中阳性症状、阴性症状、幻听、一般精神病理评分及总分均低于治疗前(P<0.05),且观察组均低于对照组(P<0.01);治疗第8周,两组AHRS评分均低于治疗前(P<0.05),且观察组治疗第4、8周均低于对照组(P<0.05);观察组知晓精神分裂症是一种疾病、个人患病程度、治疗方案及对治疗的认同度均优于对照组(P<0.05,P<0.01)。结论:医患共同决策干预能有效缓解精神分裂症伴持续性幻听患者的临床症状,提高治疗疗效和治疗依从性。     

医患共同决策干预模式在双向情感障碍患者中的应用

目的 探讨医患共同决策(SDM)干预模式在双向情感障碍(BD)患者中的应用效果.方法 选取2019年1～12月我院收治的120例BD患者,将采用SDM干预模式护理的患者归为观察组(61例),将采用常规护理的患者归为对照组(59例),两组均持续护理6个月.对比两组患者护理前、护理6个月后认知功能与自我护理能力变化.结果 ...     

基于CiteSpace的医患共同决策国内研究热点的可视化分析

目的 了解我国医患共同决策研究现状与发展趋势,为推动临床应用提供参考。方法 检索知网、万方、维普期刊数据库收录的医患共同决策相关文献,检索时限为2005年1月1日-2020年8月1日,应用CiteSpace信息可视化软件及文献计量学方法,分析医患共同决策文献的关键词、机构、作者的知识图谱。结果 共筛选出199篇有效文献,2005-2016年发文量较少且起伏不定,2017-2019年发文量迅速增加,呈上升趋势,发文量最多的年份为2019年（49篇）。作者间形成了一定的合作群,但部分发文量较多的作者并未形成合作群。高频关键词集中于医患关系、影响因素、决策辅助等方面。结论 国内医患共同决策逐步发展为研究热点,但受医患等多重因素的影响,其在实际应用中受到了诸多阻碍。应依据近年来研究趋势进行针对性研究,增强患者就医体验,建立平等的医患关系,促进医患共同决策。     

护士在癌症相关医患共同决策中的角色与功能研究进展

癌症患者所面临的决策点通常多且复杂,目前医患共同决策模式在癌症患者群体中应用较为广泛。本文将对癌症患者治护过程中的医患共同决策的相关研究进行综述,并对护士在其过程中扮演的角色进行分析讨论,以期为我国在癌症治护领域实施医患共同决策提供参考。     

Impact of Patient Acuity on Preference for Information and Autonomy in Decision Making

OBJECTIVES: To test the hypotheses that ED patients' desires for medical information and for autonomy in decision making are inversely related to increasing acuity of illness, increasing age, and lower level of formal education. METHODS: The authors conducted a prospective study of ED patients who presented for care during seven nonconsecutive 24-hour periods. Of 804 patients approached, 665 completed a questionnaire that was administered by a trained research assistant. Patients rated their desire for medical information, and for participation in medical decision making, on two 10-cm visual analog scales. Patient acuity level was determined in routine fashion by trained triage nurses, who were unaware of the nature of this study. RESULTS: Desire for information was uniformly high, and did not vary statistically between triage groups (p = 0.41). The most acutely ill patients (level I) were more likely to be excluded by the research interviewer (p < 0.001). Of included level I patients, desire to participate was not decreased (p < 0.01). Higher level of formal education (p = 0.036) and younger age (p < 0.001) were associated with greater desire for autonomy in decision making. CONCLUSION: Among ED patients able to participate, higher acuity of illness was not associated with a decreased desire for medical information. Many very acutely ill patients preferred autonomy in medical decision making. Older patients and those with less formal education expressed a lesser desire for decision-making autonomy.     

Shared Decision Making in Home Hospice Nursing Visits: A Qualitative Study

Context

Shared decisions between health care providers and patients and families are replacing the traditional physician-driven plans of care. Hospice philosophy recognizes the patient and family as a unit of care and embraces their role in decision making.

Shared Decision Making in Common Chronic Conditions: Impact of a Resident Training Workshop

Problem: Physicians must be competent in several different kinds of communication skills in order to implement shared decision making; however, these skills are not part of routine medical student education, nor are they formally taught during residency training. Intervention: We developed a 1- and 2-hour workshop curriculum for internal medicine residents to promote shared decision making in treatment decisions for four common chronic conditions: diabetes, depression, hypertension, and hyperlipidemia. The workshops included a written case exercise, a short didactic presentation on shared decision-making concepts and strategies for risk communication, and two role-playing exercises focused on decision making for depression and hyperlipidemia treatment. Context: We delivered the workshop as a required component of the resident curriculum in ambulatory medicine. To evaluate the impact of the workshop, we used written course evaluations, tracked the use of the newly introduced Decision Worksheets, and asked preceptors to perform direct observation of treatment decision conversations. Outcome: Residents were involved in the development of the workshop and helped identify key content, suggested framing for difficult topics, and confirmed the need for the skills workshop. One hundred thirty internal medicine and medicine-pediatrics residents attended 8 workshops over a 4-month period. In written cases completed before the workshop, the majority of residents indicated that they would discuss medications, but few mentioned other treatment options or documented patients’ goals and preferences in a sample encounter note with a patient with new depression symptoms. Overall, most participants (89.7%) rated the workshop as excellent or very good, and 93.5% said that they would change their practice based on what they learned. Decision Worksheets addressing diabetes, depression, hyperlipidemia, and hypertension were available on a primary care-focused intranet site and were downloaded almost 1,200 times in the first 8 months following the workshops. Preceptors were able to observe only one consult during which one of the four topics was discussed. Lessons Learned: Internal medicine residents had considerable gaps in shared decision-making skills as measured in a baseline written exercise. Residents provided valuable contributions to the development of a Decision Worksheet to be used at the point of care. Participants rated the skills workshop highly, though interns rated the exercise more useful than PGY-2 and PGY-3 residents did. The Decision Worksheets were accessed often following the sessions; however, observing the Decision Worksheets in use in real time was a challenge in the resident-faculty clinic. Additional studies are warranted to examine whether the workshop was successful in increasing residents’ ability to implement skills in practice.     

Developing a Conversation Aid to Support Shared Decision Making: Reflections on Designing Anticoagulation Choice

Patient-centered care requires that treatments respond to the problematic situation of each patient in a manner that makes intellectual, emotional, and practical sense, an achievement that requires shared decision making (SDM). To implement SDM in practice, tools—sometimes called conversation aids or decision aids—are prepared by collating, curating, and presenting high-quality, comprehensive, and up-to-date evidence. Yet, the literature offers limited guidance for how to make evidence support SDM. Herein, we describe our approach and the challenges encountered during the development of Anticoagulation Choice, a conversation aid to help patients with atrial fibrillation and their clinicians jointly consider the risk of thromboembolic stroke and decide whether and how to respond to this risk with anticoagulation.