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摘要: 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。Abstract: Over time, there have been major changes in the role of doctors and patients in decision-making. Shared Decision Making implies that doctors and patients make a decision jointly after communicating information about treatment options, benefits, and harms, and then considering the patient's values, circumstances and preference. Historical evolution, the reason why we need SDM, patients' perceptions of SDM, and how to implement SDM in clinical practice were introduced in this paper, which illuminated that medicine should be practiced with not only new evidence and techniques but also patient-centered communication skills. With shared decision-making, we can build a good doctor-patient relationship, be aware of patients' preference, and achieve optimal patient care.
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表 1 在房颤治疗中的医患共同决策访谈[17]
核心内容 举例 至少有医患双方参与 医生:为降低房颤所致的卒中风险, 有几个不同的治疗选择, 我愿意与你讨论这些选择, 并与你一起探讨哪种方式最适合你。 双方共同分享信息 医生:让我来告诉你可选择的治疗及其副反应, 以及每种治疗的风险与获益。也请你告诉我对这些治疗, 有哪些你关注的问题。 双方均表达了治疗的倾向性 医生:我倾向于首先使用β受体阻滞剂, 因为它相当安全且有效。 患者:但是你告诉我该药会导致疲乏、并有性功能障碍的副反应。我对此很关注, 我更愿意选择钙离子通道拮抗剂, 因为它也足够安全、经济。 医生:该药会降低你的心率, 但在安全范围。它会与你的降脂药有交互作用, 因此我将调整你的降脂药。你认为可以吗? 患者:可以, 如果必须要调整, 药物只要在医保报销范围就可以了。 双方最终就即将开展的治疗达成一致 医生:我们就使用钙离子通道拮抗剂达成了一致, 如果无效的话, 我们将重新评估, 并考虑使用其他控制心率的药物、抗心律失常药以及射频消融术。 患者:好的。 -
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