醫病共享決策臨床實務與挑戰

The Clinical Practice and Challenges of Shared Decision Making

傳統上醫療往往由醫師主導，近二、三十年來，以病患為中心的醫療理念應運而生，選擇醫療決策的自主性增強，接受檢查和治療時要求增多，且受到政府機構、專家團體支持；事前讓醫師和病患充分諮詢與溝通，共同達成治療決策，已成為新一代醫療的里程碑，即為「醫病共享決策」（shared decision-making, SDM）。推出以來受到許多國家的衛生機構推崇，在醫策會的推廣下，台灣全國如火如荼地推動各式各樣疾病的「醫病共同決策」方案，方興未艾。醫學倫理學專家捍衛病患的自主權，不容醫師替代病患的偏好和價值觀。良好的「醫病共享決策」，可增高病患自主性、落實人權、減省不必要檢查、降低醫療費用、改善照護品質和滿意度。但是，由於臨床情境差異，醫師、醫療團隊、病患、家屬間醫療知識水準有別，因此共同積極參與醫病共同享決策，達到預期目標，仍是一項重大挑戰，此為本文討論主題，尤重視與醫病共享決策的評估實務。

Traditionally, medical care is mainly guided by professional medical personnel. In the recent 2 to 3 decades, the concept of patient-centered medical care emerges. Patient autonomy is increasingly involved in making medical decisions. More and more patient rights are also claimed during examination and treatment process. It has been supported by government agencies, expert groups and patients. Pre-consultation and communication between doctors and patients to achieve a shared-decision making in health care has set a milestone in the new era of medical care Shared decision-making (SDM) is highly recommended by health agencies in many countries. Under the promotion policy by Joint Commission of Taiwan (JCT), many SDM models have been launched in Taiwan, and moving with great momentum. Medical ethics experts argue for patient autonomy, and physicians are not allowed to attempt to change patients' preferences and values. A good SDM policy can increase patient autonomy and implement human rights, reduce unnecessary examinations, reduce medical costs, and improve the quality and satisfaction of care. However, there are variations in clinical situation and also a big gap in professional knowledge among doctors, medical teams, patients and family, etc. Therefore, it remains a big challenge whether doctors and/or patients will take part in SDM process actively and achieves appropriate outcomes. This is the main issue discussed in this article, especially the challenge of practicingshared decision-making in surgery.