??? (Compassion)

1
?????????
?????? ???? ???? ???? ?????
2
(No Transcript)
3
???????

• ??? (Compassion)
• ?? (Competence)
• ?? (Autonomy)

4
???

• ?????????
• ??????????
• ???,???????, ???

5
??

• ??????????????
• ???????????
• ???????,???????????????????, ????

6
??

• ????????????
• ????????????, ???
• ????, ??, ???????
• ????
• ????????,???????????,????????????????,????????????
  ???

7
The Art of Patient Care in Clinical Medicine

• "... the secret of the care of the patient is in
  caring for the patient."

Francis Peabody, 1925
8

• Good communication with patients, families,
  caregivers, consultants and referring physicians
  is absolutely vital to good patient care.

9
???????

• ????
• ???
• ?????
• ???

• ??????????????

Emanuel Emanuel, JAMA 19922672221-26
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????(Paternalistic) ???????

• ????? ?????????????????
• ????????????

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???(Informative)????????

• ?????????,?????,??????
• ????????????????

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?????(Interpretive) ??????/???

• ?????????,???????????????
• ???????????????????.

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???(Deliberative) ??????/??

• ????????????????????????????
• ????????????????

14
??/? ?
??????/???
???????
??????/??
Deber et al. What Role do Patients wish to play
in treatment decision making? Arch Intern Med.
19961561414-1420
15
?????????????

• ?????
• ?????????
• ??
• ??????????
• ?????????
• ??????
• ????
• ????????
• ????????
• ????

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?????, ???V.S.??????
17
?????????

• ??????(the principle of respect for autonomy)
• ?????(the principle of non-maleficence)
• ???? (the principle of beneficence)
• ????(the principle of justice)

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??????(1)

• ????????????????????,?????????????????????????????
  ????????
• ??? (competent) ????????????????????????????,?????
  ??????????????

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??????(2)

• ?????????????????????
• ??(truthfulness)???????????,???????????????????
• ??(confidentiality)?????????????????????????????
• ????(Informed consent)???????????,???????????????
  ????

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?????

• ???????????????????,????????????????????
• ???????
• ?????????????????????????????????? (standard of
  due care)? ?
• ???????????????? ?

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????

• ?? (beneficence) ???????????????,????????????
• ??????????????
• ????,???????????????????(perfect
  duty),??????????(general beneficence) ?
• ????????????????,???????????????????,??????????
  (specific beneficence)?

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????

• ???????????????????
• ?????????? (????)
• ??????? (????)
• ????????? (????)

23
???????

• ?????????????
• ??????
• ????????
• ??, ??, ??,???
• ????
• ????
• ?????

24
?????????

• ??
• ????
• ??

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?????????

• ???????????
• ????????(decision-making capacity)???????????????
  ????????????????,?????????????
• ????????????(manipulation)???(coercion)?
• ???????????????????????????
• ??????????(voluntary)????????????

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????????

• ??(assent)
• ??(consent)
• ????(informed consent)
• ????(shared decision-making)
• ????(autonomous authorization)

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????(1)

• ??(assent)?????????????????? ??????,????????????
  ?????????????
• ??(consent)???????????????????,?????????????????(
  ??????????????),??????????????

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????(2)

• ????(informed consent)???????????????????????,???
  ???????????????????????
• ????(shared decision-making)?????????????????????
  ????????,????????????????,????????????????????????
  ???????????????????

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????(3)

• ????(autonomous authorization)????(autonomous
  action)????????(intention)??????????????(understan
  ding)????????????(freedom from undue
  influence)??????????????,?????????????????????,???
  ?????????????

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?????????????? VS ??

• ??????(professional practice standard)
  ???????????????????????
• ?????(reasonable person standard)????????????????
  ????????????????????
• ????(subjective standard)????????????????????????
  ?????

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Informed Decision Making in Office Visits

• ???????(Discuss patients role)
• ???????(Describe issue/problem)
• ??????(Delineate alternatives)
• ???????????(Discuss pros cons of alternatives)
• ???????????(Relay inherent uncertainties)
• ??????(Assess understanding)
• ???????(Ascertain patient's preference)

Braddock et al. 1997
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Types of Decision Making

• Impact on
• patient
• Minimal
• Moderate
• Extensive

Medical Opinion Consensus Wide
support Controversy
Nature of Outcome Clear, singular Multiple,
finite Uncertain, Various

• Basic
• Intermediate
• Complex

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???????????

• ???????????
• ?????????
• ?????????????

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???????

• Basic(CXR)
• Nature of decision
• Patients role OR stated preference
• Intermediate(??????)
• Basic PLUS
• Alternatives, pros/cons, understanding
• Complex(?????)
• Intermediate PLUS
• Uncertainties

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Basic Decision

• ???????CXR, ?????, ??!
• ??????????,??????????,?????????CXR.

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Intermediate Decision

• ???????????????
• ???????, ???, ???????????????, ???????????,
  ???????, ??????, ????????, ?????. ?????????

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Complex Decision

• ????????????????,?????,?????????
• ????????????, ???????????????, ?????????????.
  ????????????, ??????, ?????????????????,
  ??????????. ????????, ?????, ???. ???????????,
  ????. ??????????????. (??, ?????????????1-3)
  ????????, ??????, ?????, ?????. ????, ??????,
  ??????, ??????. ?????????

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?????????Decision-Making Capacity Assessment

• ????
• ??????
• ?????
• ????????????
• ??(?????????)

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• ???STANDARD??????????

Situation ?????????
Treatment ??????????
Alternative ??????????
No Treatment ??????????
Decision ????????????
Appreciate ??????????????
Rational ??????????
Durable ?????????,?????