Armstrong Melissa J, Mullins C Daniel
Department of Neurology, University of Florida College of Medicine, Gainesville, FL, USA.
Pharmaceutical Health Service Research Department, University of Maryland School of Pharmacy, Baltimore, MD, USA.
Value Health. 2017 Feb;20(2):292-295. doi: 10.1016/j.jval.2016.11.008.
Incorporation of patient values is a key element of patient-centered care, but consistent incorporation of patient values at the point of care is lacking. Shared decision making encourages incorporation of patient values in decision making, but associated tools often lack guidance on value assessment. In addition, focusing on patient values relating only to specific decisions misses an opportunity for a more holistic approach to value assessment that could impact other aspects of clinical encounters, including health care planning, communication, and stakeholder involvement. In this commentary, we propose a taxonomy of values underlying patient decision making and provide examples of how these impact provision of health care. The taxonomy describes four categories of patient values: global, decisional, situational, and external. Global values are personal values impacting decision making at a universal level and can include value traits and life priorities. Decisional values are the values traditionally conceptualized in decision making, including considerations such as efficacy, toxicity, quality of life, convenience, and cost. Situational values are values tied to a specific moment in time that modify patients' existing global and decisional values. Finally, discussion of external values acknowledges that many patients consider values other than their own when making decisions. Recognizing the breadth of values impacting patient decision making has implications for both overall health care delivery and shared decision making because value assessments focusing only on decisional values may miss important patient considerations. This draft taxonomy highlights different values impacting decision making and facilitates a more complete value assessment at the point of care.
纳入患者价值观是以人为本的医疗护理的关键要素，但在医疗护理过程中始终纳入患者价值观的情况却很缺乏。共同决策鼓励在决策过程中纳入患者价值观，但相关工具往往缺乏价值评估方面的指导。此外，仅关注与特定决策相关的患者价值观，会错失以更全面的方式进行价值评估的机会，而这种评估可能会影响临床诊疗的其他方面，包括医疗保健规划、沟通以及利益相关者的参与。在本评论中，我们提出了患者决策背后价值观的分类法，并举例说明这些价值观如何影响医疗保健的提供。该分类法描述了患者价值观的四个类别：全局价值观、决策价值观、情境价值观和外部价值观。全局价值观是在普遍层面影响决策的个人价值观，可包括价值特质和生活优先事项。决策价值观是传统上在决策中概念化的价值观，包括疗效、毒性、生活质量、便利性和成本等考量因素。情境价值观是与特定时刻相关的价值观，会改变患者现有的全局价值观和决策价值观。最后，对外部价值观的讨论承认，许多患者在做决策时会考虑自身以外的价值观。认识到影响患者决策的价值观范围广泛，对整体医疗保健服务和共同决策都有影响，因为仅关注决策价值观的价值评估可能会忽略患者的重要考量因素。这份分类法草案突出了影响决策的不同价值观，并有助于在医疗护理点进行更全面的价值评估。
