Sheridan Stacey L, Harris Russell P, Woolf Steven H
Division of General Medicine and Clinical Epidemiology, University of North Carolina, Chapel Hill, North Carolina, USA.
Am J Prev Med. 2004 Jan;26(1):56-66. doi: 10.1016/j.amepre.2003.09.011.
Shared decision making is a process in which patients are involved as active partners with the clinician in clarifying acceptable medical options and in choosing a preferred course of clinical care. Shared decision making offers a way of individualizing recommendations, according to patients' special needs and preferences, when some patients may benefit from an intervention but others may not. This paper clarifies how the U.S. Preventive Services Task Force (USPSTF) envisions the application of shared decision making in the execution of screening and chemoprevention. Unlike conventional USPSTF reports, this paper is neither a systematic review nor a formal recommendation. Instead, it is a concept paper that includes a commentary on the current thinking and evidence regarding shared decision making. Although the USPSTF does not endorse a specific style of decision making, it does encourage informed and joint decisions. This means that patients should be informed about preventive services before they are performed, and that the patient-clinician partnership is central to decision making. The USPSTF suggests that clinicians inform patients about preventive services for which there is clear evidence of net benefit, and, if time permits, about other services with high visibility or special individual importance. Clinicians should make sure that balanced, evidence-based information about the service (including the potential benefits and harms, alternatives, and uncertainties) is available to the patient if needed. For preventive services for which the balance of potential benefits and harms is a close call, or for which the evidence is insufficient to guide a decision for or against screening, clinicians should additionally assist patients in determining whether individual characteristics and personal preferences favor performing or not performing the preventive service. The USPSTF believes that clinicians generally have no obligation to initiate discussion about services that have either no benefit or net harm. Nonetheless, clinicians should be prepared to explain why these services are discouraged and should consider a proactive discussion for services with high visibility or special individual importance or for services for which new evidence has prompted withdrawal of previous recommendations.
共同决策是一个过程，在此过程中患者作为积极的合作伙伴与临床医生一起明确可接受的医疗选择，并选择首选的临床护理方案。当一些患者可能从某项干预措施中获益而其他患者可能不会时，共同决策提供了一种根据患者的特殊需求和偏好使建议个性化的方法。本文阐明了美国预防服务工作组（USPSTF）设想的共同决策在筛查和化学预防实施中的应用。与传统的USPSTF报告不同，本文既不是系统评价也不是正式建议。相反，它是一篇概念文件，其中包括对有关共同决策的当前思路和证据的评论。尽管USPSTF不认可特定的决策风格，但它确实鼓励明智的联合决策。这意味着在进行预防服务之前应告知患者，并且患者与临床医生的合作关系是决策的核心。USPSTF建议临床医生告知患者那些有明确净获益证据的预防服务，如果时间允许，还应告知其他具有高关注度或特殊个人重要性的服务。临床医生应确保在需要时为患者提供关于该服务的平衡的、基于证据的信息（包括潜在的益处和危害、替代方案以及不确定性）。对于潜在益处和危害的平衡难以判断，或者证据不足以指导决定是否进行筛查的预防服务，临床医生还应协助患者确定个人特征和个人偏好是否有利于进行或不进行该预防服务。USPSTF认为，临床医生通常没有义务发起关于既无益处也无净危害的服务的讨论。尽管如此，临床医生应准备好解释为什么不鼓励这些服务，并应考虑针对具有高关注度或特殊个人重要性的服务或因新证据导致先前建议被撤回的服务进行积极讨论。
