West Suffolk Hospital, Bury St Edmunds, UK.
University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
Anaesthesia. 2019 Jan;74 Suppl 1:13-19. doi: 10.1111/anae.14504.
This review on shared decision-making comes at a time when international healthcare policy, domestic law and patient expectation demand a bringing-together of the patient's values and preferences with the physician's expertise to determine the best bespoke care package for the individual. Despite robust guidance in terms of consent, the anaesthetic community have lagged behind in terms of embracing the patient-focused rather than doctor-focused aspects of shared decision-making. For many, confusion has arisen due to a conflation of informed consent, risk assessment, decision aids and shared decision-making. Although they may well be linked, they are discrete entities. The obstacles to delivering shared decision-making are many. Lack of time is the most widely cited barrier from the perspective of physicians across specialties, with little time available to the anaesthetist at the day-of-surgery pre-operative visit. A more natural place to start the process may be the pre-operative assessment clinic, especially for the 'high-risk' patient. Yet shared decision-making is for all, even the 'low-risk' patient. Another barrier is the flow and the focus of the typical anaesthetic consultation; the truncated format presents the danger of a cursory, 'time-efficient' and mechanical process as the anaesthetist assesses risk and determines the safest anaesthetic. As patients have already decided to proceed with therapy or investigation and may be more concerned about the surgery than the anaesthesia, it is often assumed they will accept whatever anaesthetic is offered and defer to the clinician's expertise - without discussion. Furthermore, shared decision-making does not stop at time of anaesthesia for the peri-operative physician. It continues until discharge and requires the anaesthetist to engage in shared decision-making for prescribing and deprescribing peri-operative medicines.
这篇关于共享决策的综述恰逢其时，因为国际医疗保健政策、国内法律和患者期望都要求将患者的价值观和偏好与医生的专业知识结合起来，以确定为个体量身定制的最佳护理方案。尽管在同意方面有强有力的指导，但麻醉学界在接受以患者为中心而不是以医生为中心的共享决策方面一直落后。对许多人来说，由于将知情同意、风险评估、决策辅助工具和共享决策混为一谈，导致产生了混淆。尽管它们可能有联系，但它们是不同的实体。提供共享决策的障碍很多。缺乏时间是所有专业医生最常提到的障碍，在手术当天的术前访视中，麻醉医生几乎没有时间。从麻醉医生的角度来看，一个更自然的起点可能是术前评估诊所，特别是对于“高风险”患者。然而，共享决策适用于所有人，即使是“低风险”患者。另一个障碍是典型麻醉咨询的流程和重点；这种简化的格式存在仓促、“高效省时”和机械过程的危险，因为麻醉医生评估风险并确定最安全的麻醉方法。由于患者已经决定继续接受治疗或检查，并且可能更关心手术而不是麻醉，因此通常假设他们会接受提供的任何麻醉方法，并听从临床医生的专业知识——而无需讨论。此外，对于围手术期医生来说，共享决策并不在麻醉时停止。它一直持续到出院，并要求麻醉医生参与围手术期药物的共享决策，包括开具和停用药物。
