醫療爭議之心理社會面向

Psychosocial Dimensions of Medical Disputes

廖士程(Shih-Cheng Liao) ； 李明濱(Ming-Been Lee) ； 李宇宙(Yue-Joe Lee)

《Journal of Medical Education》 3卷3期 (1999/09) Pp. 267-278

https://doi.org/10.6145/jme.199909_3(3).0007

摘要

醫療爭議與醫療過失訴訟是當代醫療過程中，所面臨之重大課題，除病患、家屬、以及醫療團隊同感痛苦與壓力外，對於醫療品質維護、醫療團隊與病患之自主性、以及全人照護原則之影響甚鉅。過去部分文獻曾將日漸增加之醫療爭議歸咎於社會文化之變遷、管理式醫療、以及醫病關係之特性。本文就精神醫學之觀點分析八例個案，探討醫療爭議之心理社會面向，提出預防與處理原則，並就醫學倫理敎育觀點提供建言。由本研究可發現，醫療爭議之發生與醫療團隊、病患及家屬之特性，以及當時之醫療情境有關；而其核心因素包括：災難性預後、醫療過程之風險及不確定性、急性期之危機處理、急性期後之治療策略溝通、交接班時醫療團隊之脆弱性、驟失親人之否定作用及哀慟反應、醫療團隊之特質、家属之特質與罪惡感、對災難性預後之否定作用、重要人物(VIP)相關問題、住院日數長短、以及醫療團隊轉换等。整體而言，醫病溝通之良窳以及知情同意原則之落實是否，往往與醫療爭議之發生及事後處理之難易程度相關。未來除建立推動醫病溝通問题之相關研究、建立醫療爭議及醫療訴訟危險因子之預測模式外，於醫學敎育方面，知情同意原則之落實、醫病溝通技巧之訓練、甚至醫學生醫學人文素養之提昇，均為當務之急。

關鍵字

醫病溝通 ； 醫療爭議 ； 精神科照會 ； 醫學倫理教育

並列摘要

Increasing numbers of medical disputes and medical malpractice suits have greatly impacted contemporary medical services. Some published papers have attributed these increases to managed care, to the character of doctor-patient relationship or even to trends of social evolution. Nevertheless, there is common agreement that doctor-patient communication plays an important role in the initiation of medical disputes which are correlated with psychosocial factors. There are few studies focusing on this issue from the viewpoint of consultation-liaison psychiatry and medical education. The present study describes the psychosocial aspects of medical disputes and discusses related issues of management, future studies and medical ethics education. The subjects of this study were eight common cases of psychiatric consultation referred because of communication problems in the doctor-patient relationship. The psychosocial dimensions of those medical disputes were analyzed. According to the case study, the causal factors of medical disputes were found to be associated with catastrophic outcome, medical uncertainty, effectiveness of crisis intervention, degree of continuous care, alternation of medical teams, grief reaction, denial of unfavorable outcome, guilty feeling of family members, and the characters of doctors, patients, and family members. On the whole, doctor-patient communication and informed consent had core effects on the initiation and management of medical disputes. The effectiveness of prevention of medical disputes depended on the firmness of the therapeutic alliance, adequate informed consent, the sensitivity of identifying and managing difficult patients, and elective compromises with managed care. The principles of management included immediate crisis intervention, identifying and handling feelings of denial, guilty, and grief, the commitment of continuous care, the existence of mentoring program, medical legal services of the institution, and supportive groups of the medical staff. Future studies focusing on the prevalence rate of medical disputes in a general hospital, sub-grouping of events, and provision of a predictive model are needed. It is suggested that the most effective prevention strategy may be through medical ethics education.

並列關鍵字

doctor-patient communication ； medical dispute ； consultation-liaison psychiatry ； medical ethics education