導入醫病共享決策於慢性腎臟病患者治療決策影響因素之初探

Exploring the Influences on Applying Shared Decision Making (SDM) with Chronic Kidney Disease

林依伶(Yi-Ling Lin)

指導教授 ： 高浩雲

高雄醫學大學/健康科學院/醫務管理暨醫療資訊學系碩士班/碩士(2019年)

摘要

研究目的
台灣末期腎臟病的盛行狀況與發生率高居世界之冠。當慢性腎病患者進入病程後期時，需要面臨多種腎臟替代療法的選擇，大部分的患者可能對治療方式及疾病不了解，因此需要透過更多的溝通及衛教，能讓患者更了解病情並選擇適合自己的治療方式，也能進而降低醫療糾紛的發生。近年來醫界也推出政策：「醫病共享決策」來解決及避免這些問題。其強調醫療團隊與患者基於臨床實證醫學及醫療專業，彼此交換資訊及想法，透過輔助工具及雙向溝通，共同協議出對病人最有利的醫療決策。回顧過去有關慢性腎臟病與醫病共享之相關文獻，都傾向於討論如何進行醫病共享決策，鮮少有研究探討參與醫病共享決策後在治療決策過程中的影響及患者參與醫病共享決策的意圖。

研究方法
以系統性回顧法，使用Pubmed電子資料庫，以關鍵字搜尋2014年至2018年符合條件之文獻，探討醫病共享決策對慢性腎臟病患者做治療決策時的影響。再以專家訪談法，綜合臨床專業人員之意見與經驗，分析臨床現況，最後再發展問卷。

研究結果
本研究依據研究主題及目的搜尋有關醫病共享決策對患者之影響的文章，進行文獻回顧有8篇，結果顯示了四個治療選擇的核心：資訊的傳遞、身邊他人影響、面臨死亡率、患者及選擇治療的意圖與特性，這些都與慢性腎臟病治療決策相關。

結論與建議
整合文獻結果，導入醫病共享決策可促進醫病雙方交流，可降低患者焦慮及擔憂的情況及增加患者的滿意度。患者如擁有良好的家庭支持系統，也能減輕患者的壓力及心理負擔。本研究為探討是否透過醫病共享決策的介入有其他因素會影響患者選擇治療方式，因此發展患者參與醫病共享決策對未來選擇治療方式意圖之量表。建議未來可朝患者心理層面做後續之相關研究，也建議醫療提供者透過資訊傳遞及溝通改善醫病關係。

關鍵字

醫病共享決策 ； 慢性腎臟病 ； 腎臟替代療法 ； 計畫行為理論

並列摘要

Background:
The prevalence and incidence of end-stage kidney disease in Taiwan is the highest in the world. When patients with chronic kidney disease enter the late stage of the dis-ease, they need to face a variety of kidney replacement therapy options. Most patients may not understand the treatment methods and diseases. Therefore, more communication and education are needed to enable patients to better understand the disease and choose. The treatment that suits you can also reduce the incidence of medical disputes. Recently, the medical profession has also introduced a policy "medical disease sharing decision-making" to solve and avoid these problems. It emphasizes that medical teams and patients are based on clinical evidence medicine and medical professions, exchanges information and ideas, and through tools and two-way communication, jointly agree on the most favorable medical decisions for patients. The past works of literature on the sharing of chronic kidney disease and medical disease, they tend to discuss how to make decision-making in medical and disease sharing. There are few studies focus on the impact of participation in the de-cision-making process after the decision-making of medical and disease sharing and the participation of patients in medical and disease sharing decisions.

Methods:
This study conducts the systematic review method, which use the Pubmed's elec-tronic database to search for qualified documents from 2014 to 2018 as well as to explore the impact of decision-making in patients with chronic kidney disease. Moreover, this research uses the expert interview method to comprehensive clinical professionals' opinions and experiences, analyze the clinical status and want to de-velop the questionnaire.

Results:
According to the research topic and purpose, this study searches for articles on the impact of medical decision-making on patients. There are 8 literature reviews were included for analysis. The results show the core of four treatment options: infor-mation transmission, the influence of others, mortality, patients and the choice of treatment intentions and characteristics are related to the treatment of chronic kid-ney disease decisions.

Conclusions:
Integrating the results of the literature and introducing medical decision-making can promote the communication between doctors and patients, which can reduce the anxiety and worry of patients and increase the satisfaction of patients. Patients with a good family support system can also reduce the stress and psychological burden of the patients. This study explores whether there are other factors that influence the patient's choice of treatment through the intervention of medical and disease sharing decisions. Therefore, the development of patients' participation in the deci-sion-making of the treatment decision-making method for the future choice of treatment methods is developed. It is suggested that follow-up research can be done on the psychological level of patients in the future. It is also recommended that medical providers improve the relationship between doctors and patients through information transmission and communication.

並列關鍵字

Share decision-making ； Chronic kidney disease ； Renal replacement therapy ； Theory of planned behavior

參考文獻

中文文獻

黃嘉宏、連榮達、吳明儒、陳呈旭、徐國雄 (2019). 台灣腎臟移植的過去、現在與未來. 內科學誌，doi:10.6314/JIMT.201902_30(1).07.

林小閔、李佳倫. (2015). 一位面臨血液透析抉擇病人的護理經驗. 嘉基護理,15卷1期19 - 27.

陳思穎、陳玠伊、彭靖舒、楊淑君、方基存、周宏學、唐婉如. (2018). 醫病共享決策－以Three talk model為例. 臨床醫學，81(6). doi: 10.6666/ClinMed.201806_81(6).0063

吳純怡、陳瑞貞. (2018). 運用醫病共享決策於氣切手術抉擇衝突. 台灣醫學. 22(6). doi:10.6320/FJM.201811_22(6).0003.