手術之醫病共享決策

Shared Decision Making in Surgery

成功完成手術，提升病人的健康和功能，是手術醫師與病人的主要目標；現今醫學日新月異，醫療技術、設備和醫藥日新月異，推陳出新，各有利弊。唯新式治療未能提供長期治療的實證資料，考量醫療可行性、相關法律責任、保險給付和病人滿意度等，確實需在執行醫療前，醫病雙方需在手術前應取得充分溝通和協商，共同研商醫療選項，以縮短對治療成果期待的落差。「醫病共享決策」（shared decision-making, SDM）應運而生，即醫師先對病人說明手術治療選項和風險實證資料，取得病人的充分瞭解，同時請病人提供意向、偏好和價值觀，共同選定手術治療選項，經由SDM的溝通方式，讓病人明白醫療決策內容，並得到確切治療。「醫病共享決策」雖然具有許多益處，但疾病本身具有諸多未確定性，且並非所有的療程都能預期，手術治療需處理已破損的組織後再予重建，這是一種不可逆的過程；有些重大疾病或緊急醫療等，在病情緊急下為求時效，大多由醫師說明和建議治療方式，引導病人接受較專業治療的決定，難以顧全其自主權，未能達到「醫病共享決策」的實質要求。臨床上，手術的「醫病共享決策」，成為臨床實務的重大挑戰，需因時因術制宜，才能達到手術「醫病共享決策」的精神。

Successful operation to improve the health and functions of patients is the main goal of surgeons and patients. Current medicines change rapidly day by day. Novel technologies, facilities, and medicines as well, all rapid advances have their own advantages and disadvantages. Solid long-term evidence-based medicine data of new treatments are usually not available. Considering medical feasibility, related legal issues, insurance payments, and patient satisfaction, etc. surgeons and patients need to reach a consensus through adequate communication about the options before treatment. Thus, the gap between the expected outcomes and real ones can be decreased. ''Shared decision-making'' (SDM) has been developed to fit such needs. The surgeons first explain the evidence-based options and risks of operation treatment to the patients and make them understand well. Then patients provide their intentions, preferences and values on the basis of full understanding of the relevant options. Finally, surgeons and patients can reach a consensus of operation options. SDM systems enable patients to truly understand the exact meaning of medical decisions and then receive the expected treatments. Although SDM has many benefits, however, diseases themselves have so many uncertainties, treatments courses may not be fully expected. Operations usually need to remove damaged tissue followed by reconstruction. It is an irreversible process. Some major diseases or emergency surgical situations have to be treated timely in an emergency. The in-charged surgeons need to explain and recommended treatment options, as well as guide the patient to accept more professional treatment decisions. It is difficult to consider patients’ autonomy and may not meet real SDM claim. Therefore, SDM in operation decision-making is actually a major challenge in real world practice. It is indeed necessary to take into account of timing and operations together, thus meet the essence of SDM issues in operation.