Department of Medicine, University of Washington, Seattle, Washington.
Department of Psychiatry, University of Washington, Seattle, Washington.
J Eval Clin Pract. 2019 Dec;25(6):1057-1062. doi: 10.1111/jep.13260. Epub 2019 Aug 12.
While multiple versions of shared decision making (SDM) have been advanced, most share two seemingly essential elements: (a) SDM is primarily focused on treatment choices and (b) the clinician is primarily responsible for providing options while the patient contributes values and preferences. We argue that these two elements render SDM suboptimal for clinical practice. We suggest that SDM is better viewed as collaboration in all aspects of clinical care, with clinicians needing to fully engage with the patient's experience of illness and participation in treatment. SDM can only take place within an ongoing partnership between clinician and patient, both respecting the other as a person, not as part of an isolated encounter. Respect for the patient as a person goes beyond respect for their choice. Non-interference is not the only way, or even the most important way, to respect patient autonomy. Knowing the patient as a person and providing an autonomy-supportive context for care are crucial. That is, the clinician must know the patient well enough to be able to answer the patient's question "What would you do, if you were me?" This approach acknowledges clinicians as persons, requiring them to understand patients as persons. We provide examples of such a model of SDM and assert that this pragmatic method does not require excessive time or effort on the part of clinicians or patients but does require direct and particular knowledge of the patient that is often omitted from clinical decisions.
虽然已经提出了多种版本的共享决策 (SDM)，但大多数版本都有两个看似必不可少的要素：(a) SDM 主要侧重于治疗选择，(b) 临床医生主要负责提供选择，而患者则提供价值观和偏好。我们认为，这两个要素使 SDM 在临床实践中不够理想。我们认为，SDM 最好被视为临床护理各个方面的协作，临床医生需要充分了解患者的疾病体验和治疗参与。SDM 只能在临床医生和患者之间的持续合作关系中进行，双方都尊重对方作为一个人，而不是作为一次孤立的接触的一部分。尊重患者作为一个人不仅仅是尊重他们的选择。不干涉不是尊重患者自主权的唯一方法，甚至不是最重要的方法。了解患者作为一个人，并为护理提供一个支持自主权的环境至关重要。也就是说，临床医生必须足够了解患者，才能回答患者的问题“如果你是我，你会怎么做？” 这种方法承认临床医生也是人，要求他们像了解人一样了解患者。我们提供了这种 SDM 模型的示例，并断言这种务实的方法不需要临床医生或患者花费过多的时间或精力，但确实需要对患者的直接和特定了解，而这通常在临床决策中被忽略。
