早期女性乳癌手術之醫病共享決策

Shared Decision Making for Surgery of Early Breast Cancer in Female Patients

傳統的醫療制度中，病人被動的知情同意後接受醫療處置，病人決策參與的程度較低，醫療效果不如病人期待時，容易產生醫病關係的緊張甚至醫療糾紛。醫病共享決策（shared decision making, SDM）是個實踐合作的過程，醫療人員提供專業訊息，並由病人提供他們的價值觀以及喜好，由醫病雙方共同決定對於病人最好的醫療選擇，可以確保提供以病人為中心的照護。早期乳癌治療選擇乳房全切除或是乳房保留手術加上術後放射線治療，其最佳的治療選項取決於病人的價值觀與偏好，屬於現代醫療中適合採用醫病共享決策的臨床情境。面對治療方式的選擇，當病人所接受到的資訊內容不充分，以及個人的價值與偏好未受到澄清時，病人的不確定性會增加，造成決策衝突。建議評估病人決策衝突來源，運用實證支持的決策輔助工具（patient decision aid, PDA），提升病人對於治療的知識，當病人充分參與決策、於術前獲得充足資訊，才能做出較高品質的決策，降低決策衝突。而態度及溝通技巧是醫病溝通中最重要的元素，醫療人員可以將努力的目標，放在賦權病人並增加其對於手術的信心，落實站在病人的角度，提供符合病人需求的幫助，貫徹以病人為中心的照護。本文透過美國衛生保健研究與品質機構（Agency for Healthcare Research and Quality）提出的SHARE模式，論述醫病共享決策應用於早期女性乳癌手術之選擇，以供醫療人員照護病人時的參考。

In the conventional medical practice, patient is found passive to receive medical treatment due to less input in the decision-making process. As a result, a tense relationship or medical dispute arises between patient and clinician when the medical results do not meet patient's expectation. Shared Decision Making (SDM) is a collaborative process where clinician and patient share medical advices and self-values and preferences, respectively. Both parties work together to make optimal healthcare decision, ensuring a patient-centered health care that aligns with what matters most to patient. Mastectomy and breast-conserving surgery with postoperative radiation therapy are surgical treatments for early breast cancer. The optimal treatment decision is made according to patient's preference and values, thus presents a clinical scenario for SDM in current medical practice. In making decision on treatments, patient is likely to be uncertain and the conflict arises when the medical information is insufficient; or her values and preference are not adequately taken. It is recommended that the cause of decisional conflict should be assessed and the patient decision aid (PDA) should be used to enhance patient's knowledge of treatment. Patient's fully share of decision-making and good understanding prior to the surgery could lead to high-quality decision and decrease of decisional conflict. Attitude and communication skills of both parties are vital to a good clinician-patient relationship. Clinicians could give more trust to patient, to build his/her confidence in the surgery, to meet his/her need of support in the treatment, and to complete a patient-centered health care. This article presents the SHARE model utilized by Agency for Healthcare Research and Quality (AHRQ) in a clinical scenario, detailing the shared decision-making process in choosing surgical options for early breast cancer. This article attempts to provide an enlightening reference for clinicians in taking care of female patients with early breast cancer.