癌症护理中的决策是如何做出的？一项通过对当前实践进行参与观察的定性研究。
How are decisions made in cancer care? A qualitative study using participant observation of current practice.
作者信息
Hahlweg Pola, Härter Martin, Nestoriuc Yvonne, Scholl Isabelle
机构信息
Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
出版信息
BMJ Open. 2017 Sep 27;7(9):e016360. doi: 10.1136/bmjopen-2017-016360.
OBJECTIVES
Shared decision-making has continuously gained importance over the last years. However, few studies have investigated the current state of shared decision-making implementation in routine cancer care. This study aimed to investigate how treatment decisions are made in routine cancer care and to explore barriers and facilitators to shared decision-making using an observational approach (three independent observers). Furthermore, the study aimed to extend the understanding of current decision-making processes beyond the dyadic physician-patient interaction.
DESIGN
Cross-sectional qualitative study using participant observation with semistructured field notes, which were analysed using qualitative content analysis as described by Hsieh and Shannon.
SETTING AND PARTICIPANTS
Field notes from participant observations were collected at n=54 outpatient consultations and during two 1-week-long observations at two inpatient wards in different clinics of one comprehensive cancer centre in Germany.
RESULTS
Most of the time, either one physician alone or a group of physicians made the treatment decisions. Patients were seldom actively involved. Patients who were 'active' (ie, asked questions, demanded participation, opposed treatment recommendations) facilitated shared decision-making. Time pressure, frequent alternation of responsible physicians and poor coordination of care were the main observed barriers for shared decision-making. We found high variation in decision-making behaviour between different physicians as well as the same physician with different patients.
CONCLUSION
Most of the time physicians made the treatment decisions. Shared decision-making was very rarely implemented in current routine cancer care. The entire decision-making process was not observed to follow the principles of shared decision-making. However, some aspects of shared decision-making were occasionally incorporated. Individual as well as organisational factors were found to influence the degree of shared decision-making. If future routine cancer care wishes to follow the principles of shared decision-making, strategies are needed to foster shared decision-making in routine cancer care.
目的
在过去几年中，共同决策的重要性不断增加。然而，很少有研究调查常规癌症护理中共同决策实施的现状。本研究旨在调查常规癌症护理中治疗决策是如何做出的，并使用观察法（三名独立观察者）探索共同决策的障碍和促进因素。此外，该研究旨在扩展对当前决策过程的理解，超越医患二元互动。
设计
采用参与观察和半结构化实地笔记的横断面定性研究，使用谢和香农描述的定性内容分析法进行分析。
设置和参与者
在德国一家综合癌症中心不同诊所的54次门诊咨询以及两个住院病房为期两周的观察期间，收集参与观察的实地笔记。
结果
大多数情况下，由一名医生或一组医生做出治疗决策。患者很少积极参与。“积极”的患者（即提问、要求参与、反对治疗建议）促进了共同决策。时间压力、负责医生的频繁更替以及护理协调不善是共同决策中观察到的主要障碍。我们发现不同医生之间以及同一名医生与不同患者之间的决策行为存在很大差异。
结论
大多数情况下由医生做出治疗决策。在当前的常规癌症护理中，共同决策很少得到实施。整个决策过程未遵循共同决策的原则。然而，共同决策的某些方面偶尔会被纳入。发现个人和组织因素会影响共同决策的程度。如果未来的常规癌症护理希望遵循共同决策的原则，就需要采取策略来促进常规癌症护理中的共同决策。
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