William R. Lewis  美国克利夫兰大学医院副教授，临床心脏病学杂志主编；主要研究领域为心血管疾病、心房颤动和心脏电生理。

　　<International Circulation>:Your presentation at ACC.12 was on shared decision-making with patients. Could you outline some of the principles involved?
 

　　《国际循环》：您在2012年ACC年会上做了题为“与患者共同决策”的演讲，您能否介绍一下其中涉及的主要原则有哪些？
　　Dr Lewis: We talked about the fact that shared decision-making is something that many physicians， particularly in the United States， think they do already. They think that informed consent is shared decision-making. In reality， that is not the case. What we find is that when we look at patients’ knowledge of the risk and benefits and alternatives for the procedure they are about to undergo， it does not match at all with the true risk-benefits and outcomes of a particular procedure. There is clearly a disconnect between what patients should know or the true reality of what they are undergoing and what they actually do know. Therefore the concept of shared decision-making is to narrow that gap so that the patients’ expectations of what is going to happen to them are actually what the true expectations are. In addition， in many cases (and not all cases because some physicians are very good at doing this)， one of the things that we have done poorly in the past as physicians is understanding what the patient’s specific needs and wants are as well. For example， a patient who values the avoidance of long term bleeding risk over the increased risk of restenosis may choose a bare metal stent over a drug-eluting stent. That is the other component of shared decision-making. There are really a few components to shared decision-making. Firstly， there is a full understanding by the patients of what the risk， benefits， alternatives and expected outcomes are. The second element is having them understand what this means.. It needs to be presented to them in a way that they understand it. Thirdly it needs to take into account their wants and needs. Those will be different according to each individual. It is a complicated process because every decision we make has a lot of alternatives. As physicians we know these alternatives， but communicating the intricacies of each alternative and incorporating an individual patient’s values takes a lot of time. A better and more prepared patient makes such a conversation more efficient. So this process gets extremely complicated and to do it well requires a lot of insight. What the American College of Cardiology is trying to do is to put a lot of that information in one place for easy patient access.
 

认知与现实的差距
    我们讨论了是“与患者共同决策”，大多数医生（尤其是在美国）认为他们已经这样做了，他们认为知情同意就是共同决策的体现。但事实并非如此。患者对其要进行的治疗的风险与获益以及可选的替代治疗的了解并不完全。对其正在做的事情，患者应该知晓和实际知晓的情况存在脱节。共同决策的理念则有助于缩小上述差距，从而使患者对即将发生在自己身上的事情有正确的预期；此外，很多情况下，作为医生我们在理解患者的需求和愿望方面做得并不够好。这是共同决策理念的另一层含义。

共同决策的具体内容

    确实有很多东西需要医生和患者共同决策。首先，要让患者对治疗的风险、获益、替代选择及预期结局有充分了解；其次，需要医生用患者能够理解的方式使患者真正理解上述内容；第三，要考虑到患者的需求和愿望，当然这会因人而异。这是个复杂的过程，因为我们所做的每个决定都有很多替代选择。每个患者都存在很多对其有利或不利的情况，这在一定程度上决定了他们的临床结局。不同患者有不同的预期，其结局也不同，这使共同决策变得更为复杂，只有深入洞察才能作好。

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