從冠狀動脈病人探討醫病共享決策意願相關因子

Abstract

研究背景與目的 相較因循於父權主義的傳統醫病關係，醫病共享決策是近幾年來在國內外大力推行的醫療政策，其目的為希望醫師與病患，能夠透過醫師分享實證醫學資訊，病患表達選擇偏好，最後由雙方共同決策的模式，歐美大約在西元1980年代開始調查病患參與醫療決策的意願，於西元1997年形成醫病共享決策的架構，而後開發出相關輔助工具，而儘管台灣於西元2016年正式開始推動醫病共享決策，但在台灣及亞洲鮮有研究探討病患參與醫療決策之意願，故本研究嘗試使用問卷調查之方式，去了解台灣病患對於參與醫療決策之意願。 研究方法 本研究以自主偏好問卷(the autonomy preference index)、控制偏好量表(control preference scale)針對彰化基督教醫院之冠狀動脈疾病患者，做為評估病患參與醫療決策意願之工具，另外以決策品質問卷(Decisional quality instrument)中的部分項目以及基本資料作為變數，有效問卷數目為，以STATA 14作為統計分析工具。 結果 研究結果發現，收納104位病患中，大部分民眾確實有意願參與醫療決策，使用自主偏好問卷調查，其意願分數為51.96±11.52分(分數範圍0-100分)，屬於偏向有意願參與醫療決策，另外控制偏好量表則顯示有58.65%的民眾有意願參與醫療決策，且其中21.15%的受試者更偏向由自己做最後決策。但仍需注意並非每一個病患都有意願參與決策，特別是較年長(p=0.02)以及男性病患(p=0.01)，另外較低學歷之病患亦有較不傾向參與決策之趨勢。除此之外，隨著疾病嚴重度增加，病患參與醫療決策的意願降低，而此現象在男性特別明顯。 結論 根據本研究之結果，多數人願意接受醫病共享決策，在台灣推行醫病共享決策應為適當之政策，但仍應對醫療端及病患端多加以教育，未來我們必須去了解是甚麼樣的因素會影響到病患參與的意願，並藉由教育的方式，使醫病都能了解到醫病共享決策所帶來的好處，若在相當透徹了解的狀態下，病患仍舊不願參與決策，我們也應當尊重病患的意願，透過適切的代理決定做出醫療決策，以求同時獲得雙方最大的好處

Background In contrast to the traditional doctor-patient relationship based on paternalism, shared decision-making was popular decision-making strategies in recent years globally. The purpose of shared decision-making is to include mainly the physician and the patient in decision-making process, in which the physician shares the available evidence to the patient, the patient is informed, and then the decision is facilitated accordingly. Around A.D. 1980, there were some studies investigating patients’ willingness to participate in the medical decision-making process. Charles et al. first developed the theoretical framework of shared decision-making in 1997, and thereafter, the decision aids were developed for shared decision-making. Since 2016, the government of Taiwan has been promoting the strategies of shared decision-making. However, few studies have been focused on patients’ willingness to participate in clinical decision-making process in an East Asian society in which family determination is usually honored. The objective of this study was to investigate the patient’s preferences about participating in medical decision-making process. Methods This was a cross-sectional study conducted in a medical center located at Changhua, Taiwan in 2017. We invited the patients consecutively admitted with coronary artery disease from June 2, 2017 to August 8, 2017 to participate in this study. All participants were required to complete the questionnaires of “the autonomy preference index” and “control preference scale”, all of which investigates participants’ willingness to participate in medical decision-making. We also collected the demographic characteristics as the confounding variables. The linear relationship between two continuous variables, and between a continuous variable and a categorical variable were examined using Pearson’s correlation coefficient and Spearman’s rank correlation coefficient, respectively. Multivariate linear regression analysis was used to examine the relationship between an independent variable of interest and the shared decision-making preferences. All statistical analyses were carried out using STATA 14.0 MP for Windows PC. Results A total of 104 patients participated in this study and completed the questionnaires. The decision-making preference score was 51.96±11.52 (a score range of 0-100) in the autonomy preference index which showed the patients’ willingness to actively participate in the decision-making process. By the questionnaire of control preference scale, 58.65% of the participants preferred to participate actively in the decision-making process, and 21.15% of them preferred to make medical decision solely by self. Older (p=0.02) and male (p=0.01) participants were reluctant to participate in the decision-making process as compared to younger and female participants, respectively. Similar findings were identified in the participants with the educational level of junior high school or lower(p=0.16). Otherwise, the preferences of the participants with severe clinical illnesses to participate in decision-making declined, particularly in the male group. Conclusion According to the study results, a majority of the participants favored shared decision-making, and thus, it is appropriate to promote shared decision-making in Taiwan. Nevertheless, it is important to promote shared decision-making by educating both physicians and patients. Future studies may be focused on investigating the factors associated with patients’ preferences for decision-making. If patients declined to be included in the decision-making process, their preferences should be respected. The decision-making may be facilitated by consulting the surrogate of the patient.