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临床实践中的患者价值观Thevaluesofpatientsinclinicalpractice主要内容ThemaincontentpatientvaluesandpreferencesAdjustthetreatmentPatientparticipationindecision-makingmodelModelofevidencebasedclinicaldecisionspatientpreferenceResearchEvidence依据是否充分clinicalcircumstances适用于临床情境•具有可操作性•经济成本可接受•具有安全性可用性评价•专家论证会）•焦点组访谈讨论Clinicalexpertise循证医学面临的重要挑战？如何在临床决策中有效地融合患者的价值观与意愿？Howtoeffectivelyfusethepatient'svaluesandpreferencesinclinicaldecisionmaking?whataretheimportantchallengesofevidence-basedmedicine?一、患者价值观与意愿patientvaluesandpreferences一、不同患者的价值观不尽相同Differentpatientswithdifferentvalues二、为什么存在患者价值观与意愿Whypatientvaluesandpreferencesexist三、认识医生与患者价值观的差异Understandingthedifferencesbetweendoctorsandpatients'values四、正确引导患者价值观Correctlyguidethepatientvalues五、家庭与患者自主价值观Familyandpatients'selfvalues六、患者价值取向在临床决策中的限度Thelimitofpatient'svalueorientationinclinicaldecisionmaking一、不同患者的价值观不尽相同Differentpatientswithdifferentvalues1、不同经历,患者对同一治疗措施的选择不同。Differentexperience,thechoiceofpatientsonthesametreatmentmeasuresaredifferent.心房纤颤的患者面临发生脑卒中的风险:服用法华林次年发生卒中的可能性从2%将至1%，但服药、做血液检查、使活动受限、轻度出血或大量胃肠道出血的风险可能增加1%。Atrialfibrillationpatientsfacingtheriskofstroke:Thepossibilityoftakingwarfarinforstrokeinsecondyearsfrom2%to1%,buttheriskoftakingmedication,doingbloodtests,makingactivitylimited,mildbleeding,oralargenumberofgastrointestinalbleedingmayincreaseby1%.一、不同患者的价值观不尽相同Differentpatientswithdifferentvalues2、不同预后,患者的选择不同Differentprognosis,thechoiceofpatientsisdifferent前Pr列腺癌手术ostatecancersurgery：生存质量与生存时间的考量。Reflectiononqualityoflifeandsurvivaltime.一、不同患者的价值观不尽相同3、不同的信仰，医疗环境Differentfaiths,andthemedicalenvironment输血：宗教信仰,严禁患者接受异体血。Bloodtransfusion：Religiousbeliefs,itisforbiddentopatientsreceivedallogeneicblood.胸痛：身处偏远地区，阿司匹林是仅有的有效药。Chestpain：Inremoteareas,aspirinistheonlyeffectivedrug.一、不同患者的价值观不尽相同4、不同的愿望differentdesires晚期癌症患者情愿忍受大剂量化疗的副作用来延长生命，为的是等待女儿的婚礼、孙儿的出生.Thesideeffectsofadvancedcancerpatientstosufferhighdosesofchemotherapytoprolonghislife,iswaitingforherdaughter'swedding,thebirthofgrandchild.二、为什么存在患者价值观与意愿Whypatientvaluesandpreferencesexist【复杂医疗外问题】【Complicatedoutsidemedicalproblems】v经济、心理、婚姻状况、工作、价值观、愿望；vEconomic,psychological,maritalstatus,work,values,aspirations；v复杂社会关系和医患矛盾、亲人群体意见；vComplexsocialrelationsandthecontradictionbetweendoctorsandpatients,theviewsoffamilygroups；v长期患病带来的各种问题,压力;vVariousproblemsandstresscausedbylong-termillness;v与他人的争吵或纠纷等。vThequarrelwithothersordisputes,etc.二、为什么存在患者价值观与意愿【关注价值观及意愿的效益】【Payattentiontopatientvaluesandthebenefitofpreferences】V帮助患者选择最佳治疗方案，提高患者治疗依从性；Helppatientstochoosethebesttreatment,improvepatientcompliance；V缓解医患关系，构建和谐诊疗环境。Alleviatethedoctor-patientrelationship,buildaharmoniousmedicalenvironment三、认识医生患者价值观的差异Knowthedifferencebetweenthedoctorvaluesandpatientvalues1.关注：客观生理指标与主观感受的矛盾v指标（检验，影像及功能）v感受（恐惧、无助、疼痛、限制活动、对智力影响、被尊重程度、生活质量）1.Focuson：ThecontradictionbetweenobjectivephysiologicalindexesandsubjectivefeelingvIndicators(inspection,imageandfunction)vFeelings(fear,helplessness,pain,restrictedactivity,intellectualinfluence,respect,qualityoflife)=21838337三、认识医生患者价值观的差异Knowthedifferencebetweenthedoctorvaluesandpatientvalues2.关注：中间指标与终点指标的矛盾v不良反应、并发症、生存质量、康复程度，v生存时间、疾病复发、恶化、纤维化与癌变。v2.Focuson：ThecontradictionbetweentheintermediateindexandtheendpointvAdversereactions,complications,qualityoflife,rehabilitationdegreevSurvivaltime,diseaserecurrence,progression,fibrosisandcarcinogenesis.=21838337四、正确引导患者价值观Correctlyguidethepatientvalues研究发现：患者越是参与循证决策，理解所获得的证据，作出的选择就越能代表自己的愿望和价值观。Studyfound：Themorepatientsareinvolvedinevidence-baseddecisionmaking,theunderstandingoftheevidence,themoreabletomakethechoiceonbehalfoftheirowndesireandvalues.四、正确引导患者价值观正确引导：1.知晓患者:早已有的多种不同选择2.了解患者:对疾病的体验,所处社会环境、行为习惯、价值取向、选择偏好和对风险的态度。3.提供信息：治疗费用、利弊、并发症、治疗方案产生的后果等。Correctguidance：1.Knowpatients:havesomedifferentoptions2.Understandingofpatients:theexperienceofthedisease,thesocialenvironment,behaviorhabits,valueorientation,choicepreferenceandattitudetowardsrisk.3.Provideinformation:treatmentcosts,advantagesanddisadvantages,complications,treatmentoptions,suchastheconsequences.vPierce研究：48例乳腺癌患者选择时的看法:①单纯乳房切除;②肿瘤切除+放射治疗。vierceStudy:48casesofbreastcancerpatientschoosetoview:①simplemastectomy;②tumorexcisionandradiotherapy案例v结果显示患者有5个共同考虑：①期望：手术是否快和容易?②安全：放射治疗癌症彻底吗?③存活：手术可延长生命多长时问?④康复：术后恢复正常的程度怎样?⑤完整：术后乳房或身体完整程度如何?vTheresultsshowedthatthepatientshad5commonconsiderations：①Expectations:whethertheoperationisfastandeasy?②Safety:radiationtherapyforcancercompletely?③Survival:howlongcanoperationprolongthelifetime④Thedegreeofpostoperativerehabilitation:backtonormal?⑤Complete:howisthedegreeofthebreastorthebodycomplete?案例【决策要素】GodernGuyatt等提出临床决策包括3个主要因素：l探索患者价值观；l掌握信息；l实际决策。【decisionelement】GuyattGodernetal.Proposedclinicaldecisionmakingincluding3mainfactors：lExploringthevaluesofpatients；lMasterinformation；lPracticaldecision.【决策方式】【Decisionmethod】u医生提供信息，自己决策；uDoctorsprovideinformation,thenpatientmakedecisionsthemselves；u医生提供信息，医生决策；uDoctorsprovideinformationandma