Edwards Adrian, Elwyn Glyn
Department of General practice, Centre for Health Sciences Research, Cardiff University, Cardiff, UK.
Health Expect. 2006 Dec;9(4):307-20. doi: 10.1111/j.1369-7625.2006.00401.x.
Shared decision making has practical implications for everyday health care. However, it stems from largely theoretical frameworks and is not widely implemented in routine practice.
We undertook an empirical study to inform understanding of shared decision making and how it can be operationalized more widely.
The study involved patients visiting UK general practitioners already well experienced in shared decision making. After these consultations, semi-structured telephone interviews were conducted and analysed using the constant comparative method of content analysis.
All patients described at least some components of shared decision making but half appeared to perceive the decision as shared and half as 'patient-led'. However, patients exhibited some uncertainty about who had made the decision, reflecting different meanings of decision making from those described in the literature. A distinction is indicated between the process of involvement (option portrayal, exchange of information and exploring preferences for who makes the decision) and the actual decisional responsibility (who makes the decision). The process of involvement appeared to deliver benefits for patients, not the action of making the decision. Preferences for decisional responsibility varied during some consultations, generating unsatisfactory interactions when actual decisional responsibility did not align with patient preferences at that stage of a consultation. However, when conducted well, shared decision making enhanced reported satisfaction, understanding and confidence in the decisions.
Practitioners can focus more on the process of involving patients in decision making rather than attaching importance to who actually makes the decision. They also need to be aware of the potential for changing patient preferences for decisional responsibility during a consultation and address non-alignment of patient preferences with the actual model of decision making if this occurs.
共同决策对日常医疗保健具有实际意义。然而，它主要源于理论框架，在常规实践中并未得到广泛应用。
我们进行了一项实证研究，以增进对共同决策的理解以及如何更广泛地将其付诸实践。
该研究涉及拜访英国已经在共同决策方面经验丰富的全科医生的患者。在这些会诊之后，进行了半结构化电话访谈，并使用内容分析的持续比较法进行分析。
所有患者都描述了共同决策的至少一些组成部分，但一半患者似乎认为决策是共同做出的，另一半则认为是“患者主导”的。然而，患者对于谁做出了决策表现出一些不确定性，这反映了与文献中所描述的决策含义不同的决策意义。在参与过程（选项描述、信息交流以及探讨谁来做决策的偏好）和实际决策责任（谁做决策）之间存在区别。参与过程似乎给患者带来了益处，而非决策行为本身。在某些会诊过程中，对决策责任的偏好会发生变化，当实际决策责任在会诊的那个阶段与患者偏好不一致时，就会产生不尽如人意的互动。然而，如果实施得当，共同决策会提高报告的满意度、对决策的理解以及信心。
从业者可以更多地关注让患者参与决策的过程，而不是看重谁实际做出了决策。他们还需要意识到在会诊期间患者对决策责任的偏好可能发生变化，如果出现这种情况，要处理好患者偏好与实际决策模式不一致的问题。
