醫證醫學三要素 (3E)
實證醫學核心與鴻溝
提出問題
知識鴻溝
搜尋及評讀文獻證據等級
執行不一致
應用及評估
環境
(Environment)
醫療人員 (Clinicians)
患者 (Patients) 醫療知識
專家
身體狀況 專家 醫病共享決策
(SDM)
溝通=知情同意
醫師對病患詳細說明病情，並就 因應之檢查或治療提供充分之資 訊，病患在充分理解後做出承諾，
在沒有受任何強制之自由立場下，
選擇檢查或治療之方法，而醫師 則根據此同意進行醫療1
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1. At least two participants-physician and patient be involved
2. Both parties share information
3. Both parties take steps to build a consensus about the preferred
treatment
4. An agreement is reached on the
treatment to implement
1 Charles Cathy醫病共享決策操作型定義
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1. 尚無明確實證結果之處置和用藥 2. 嚴重且致命的疾病
3. 可能有重大身心功能、形象改變或併 發症的處置和疾病
4. 需要長期服用的藥物
5. 醫療不確定性比重越大的情況，例如 複雜疾病或多重處置和用藥選擇
醫病共享決策時機
1. 邀請病人參與 (Invite patient to participate) 2. 向病人說明疾病、治療(檢查)方案選擇(Present
options)
3. 向病人提供所有治療方案的比較資訊(Provide information on benefits and risks)
4. 了解病人對治療方案的偏好 (Assist patient in evaluating options based on their goals and concerns)
5. 向病人分析治療方案的優劣 (Facilitate deliberation and decision making)
6. 支持病人依其價值觀進行醫病共享決策 (Assist with implementation)
醫病共享決策操作型步驟
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選項對話 Option talk
建議引導三部驟
選擇對話 Choice talk
決策對話 Decision talk
回顧病情 提供資訊 個人醫療 觀察反應
確認知識 列出選項 分析好壞 決策工具
再次分析 共同決策
SDM引導員
SDM工具 SDM指引 確認需求
SDM達成 開始治療
Renal Failure: What type of therapy should I have?
1
Get the information
2
Compare options
3
Your feelings
4
Your Decision
5
Quiz yourself
6
Your summary
Get the information
1. Your options:
Option 1: Hemodialysis
Option 2: Peritoneal dialysis 2. Key points to remember
Dialysis can help you feel better and live longer, but it is not a cure for kidney failure. After you start dialysis, you will need to keep doing it to stay as healthy as possible.
3. FAQs
4. Credits and references
Renal Failure: What type of therapy should I have?
1
Get the information
2
Compare options
3
Your feelings
4
Your Decision
5
Quiz yourself
6
Your summary
Compare options
Comparison
Hemodialysis Peritoneal Dialysis
What is usually
involved Benefits Risks and side effects
Renal Failure: What type of therapy should I have?
1
Get the information
2
Compare options
3
Your feelings
4
Your Decision
5
Quiz yourself
6
Your summary
Your feelings
醫病共享決策
1. 實證醫學評讀提供證據和比較依據 ROB 2.0 / ROBINS-I / GRADE /
Guidelines
2. 確認病人認知，釐清問題和分析好壞 Share decision aids (衛教單張 / 冊子 / 網路資源 / 多媒體影音)
跨領域團隊合作
強調圖像化 / 語言簡單化 / 自行使用
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健康識能
1
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醫病共享決策的實證醫學
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醫病共享決策的實證醫學
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Outcomes
Illustrative Comparative Risks (95% CI) No. of Participants
(studies)
Certainty of the Evidence (GRADE)
Assumed Risk [Control]
Corresponding Risk [Experimental]
Intervention targeting patients compared to usual care
SDM OBOM (F/U 6mths)
SMD 0.54 (-0.13-1.22) 424 (4 RT) Very Low
SDM PROM (F/U 3yrs)
SMD 0.32 (0.16-0.48) 1386 (9 RT) Very Low
Decision Regret (F/U 6mths)
SMD -0.10 (-0.39-0.19) 212 (1 RT) Very Low
Health-related QOF (physical)
(F/U 3mths)
SMD 0.00 (-0.36-0.36) 116 (1 RT) Very Low
Health-related QOF (mental)
(F/U 3mths)
SMD 0.10 (-0.26-0.46) 116 (1 RT) Very Low
醫病共享決策
1. 結論 It is uncertain whether any interventions for increasing the use of SDM by healthcare professionals are effective because the
certainty of the evidence is low or very low.
2. 87 studies (45,641 patients and 3113 healthcare professionals) mainly in the USA, Germany,
Canada and the Netherlands.
3. Heterogeneity between studies, possible
sources of error, reporting bias, insignificant outcomes
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