醫病共享決策之迷思

The Myths of Shared Decision Making

成功改善病人的健康和功能，是醫師與病人的共同目標；現代醫學進展快速，各種醫療技術、設備和藥物推陳出新，加上新式和舊式醫療方法並存，醫師有其擅長或喜好的治療技術與策略，且各人病況不同，醫療體系也有差異，因此在醫病溝通上需要創新。該制度須能結合人權理念和實證醫學的資料，同時考量可行性、時效性、病人的偏好和期待、相關法律責任、保險給付和滿意度等，在執行醫療前，醫病雙方需先充分溝通和協商合適的醫療選項，此即「醫病共享決策」（shared decision making，以下簡稱SDM）。推出以來，廣受推崇，然而各國醫療體系和保險制度不同，且醫師對病人說明治療選項和風險時，所取用的實證資料和專家臨床治療指引可能出現落差。此外，即使醫學快速進步，新穎的醫療項目需接受時間的驗證，才能提供實證的成效驗證。因此在醫師和病人溝通時，難免未能充分契合理想。前述種種因素，可能成為推行SDM的阻礙。此外，上疾病本身具有諸多未確定性，療程中可能出現意外情境，導致必須變更原先的治療規劃等；而重大疾病或緊急醫療等治療方式，大多由醫師說明和建議，也有違病人自主權，未能達到SDM的實質要求。前述種種因素，成為推行SDM的重大挑戰，本文討論相關的迷思，並提供因應解決之道，以期能順利推行SDM。

Successfully improving the health and function of patients are the common goals of physicians and patients. Modern medicine progresses rapidly, with various medical technologies, equipment and drugs being developed. In addition, coexistence of newly developed and old medical options, physicians having their own or preferred treatment techniques and strategies, and medical conditions as well as medical systems are also different. Therefore, a new method is needed for doctor-patient communication. Such a system has to take into account of human rights concepts, evidence-based medical data, while considering feasibility, optimal timing, patient preferences and expectations, related legal responsibilities, insurance payment and satisfaction, etc. Before medical treatment, both health providers and patients need to fully communicate and negotiate the appropriate medical options, i.e., shared decision-making, SDM. Since its introduction, SDM has become widely accepted. However, medical systems and insurance systems are different among countries. When health providers explain to patients about treatment options and risks, a big gap may exist between evidence-based data and expert clinical treatment guidelines. Furthermore, even though the advance of medicine is rapid, an innovative medical option needs to be verified after a period of time before evidence-based results can be assessed. Therefore, during the communication between doctors and patients, it is inevitable that there is a possibility of suboptimal understanding. These aforementioned factors may be an obstacle to the implementation of ＂sharing decision-making＂. Furthermore, many uncertainties of disease itself and unexpected situations arising during the course of treatment may cause the necessary change of original treatment plan. Treatment of major or emergency diseases are mostly explained and recommended by doctors who also violate the autonomy of patients and fail to meet the substantive requirements of ＂sharing decision-making＂. These factors have become the major challenges in the implementation of ＂sharing decision-making＂. This article discusses the relevant myths and provides some suggestion of solutions, thus help promoting ＂sharing decision-making＂.