Development of a Decision Aid for Family Surrogate Decision Makers of Critically Ill Patients Requiring Renal Replacement Therapy in ICU:A User-Centered Design for Rapid Prototyping

Objectives Renal replacement therapy(RRT)is increasingly adopted for critically ill patients diagnosed with acute kidney injury,but the optimal time for initiation remains unclear and prognosis is uncertain,leading to medical complexity,ethical conflicts,and decision dilemmas in intensive care unit(ICU)settings.This study aimed to develop a decision aid(DA)for the family surrogate of critically ill patients to support their engagement in shared decision-making process with clinicians.Methods Development of DA employed a systematic process with user-centered design(UCD)principle,which included:(i)competitive analysis:searched,screened,and assessed the existing DAs to gather insights for design strategies,developmental techniques,and functionalities;(ii)user needs assessment:interviewed family surrogates in our hospital to explore target user group's decision-making experience and identify their unmet needs;(iii)evidence syntheses:integrate latest clinical evidence and pertinent information to inform the content development of DA.Results The competitive analysis included 16 relevant DAs,from which we derived valuable insights using existing resources.User decision needs were explored among a cohort of 15 family surrogates,revealing four thematic issues in decision-making,including stuck into dilemmas,sense of uncertainty,limited capacity,and delayed decision confirmation.A total of 27 articles were included for evidence syntheses.Relevant decision making knowledge on disease and treatment,as delineated in the literature sourced from decision support system or clinical guidelines,were formatted as the foundational knowledge base.Twenty-one items of evidence were extracted and integrated into the content panels of benefits and risks of RRT,possible outcomes,and reasons to choose.The DA was drafted into a web-based phototype using the elements of UCD.This platform could guide users in their preparation of decision-making through a sequential four-step process:identifying treatment options,weighing the benefits and risks,clarifying personal preferences and values,and formulating a schedule for formal shared decision-making with clinicians.Conclusions We developed a rapid prototype of DA tailored for family surrogate decision makers of critically ill patients in need of RRT in ICU setting.Future studies are needed to evaluate its usability,feasibility,and clinical effects of this intervention.

Management of gastroesophageal reflux disease: Patient and physician communication challenges and shared decision making

Gastroesophageal reflux disease(GERD) is a common upper esophageal condition and typical symptoms can include heartburn and sensation of regurgitation while atypical symptoms include chronic cough, asthma, hoarseness, dyspepsia and nausea. Typically, diag-nosis is presumptive given the presence of typical and atypical symptoms and is an indication for empiric therapy. Treatment management can include lifestyle modifications and/or medication therapy with proton pump inhibitor(PPI) class being the preferred and most effective. Complete symptom resolution is not always achieved and long-term PPI therapy can put patients at risk for serious side effects and needless expense. The brain-gut connection and hypervigilance plays an important role in symptom resolution and treatment success, especially in the case of non-PPI responders. Hypervigilance is a combination of increased esophageal sensory sensitivity in combination with exaggerated threat perception surrounding esophageal symptoms. Hypervigilance requires a different approach to GERD managements, where continued PPI therapy and surgery are usually not recommended. Rather, helping physicians and patients understand the brain-gut connection can guide and improve care.Education and reassurance should be the main pillars or treatment. However, it is important not to suggest the symptoms are due to anxiety alone, this often leads to patient dissatisfaction. Patient dissatisfaction with treatment reveals the need for a more patient-centered approach to GERD management and better communication between patients and providers. Shared decision making(SDM) with the incorporation of patient-reported outcomes(PRO) promotes patient adherence and satisfaction. SDM is a joint discussion between clinician and patient in which a mutually shared solution is explored for GERD symptoms. For SDM to work the physician needs to capture patients' perceptions which may not be obtained in the standard interview. This can be done through the use of PROs which promote a dialogue with patients about their symptoms and treatment priorities in the context of the SDM patient encounter. SDM could potentially help in the management of patient expectations for GERD treatment, ultimately positively impacting their health-related quality of life.

PSA-based prostate cancer screening： the role of active surveillance and informed and shared decision making

Since the first publication describing the identification of prostate-specific antigen （PSA） in the 1960s, much progress has been made. The PSA test changed from being initially a monitoring tool to being also used as a diagnostic tool. Over time, the test has been heavily debated due to its lack of sensitivity and specificity. However, up to now the PSA test is still the only biomarker for the detection and monitoring of prostate cancer. PSA-based screening for prostate cancer is associated with a high proportion of unnecessary testing and overdiagnosis with subsequent overtreatment. In the early years of screening for prostate cancer, high rates of uptake were very important. However, over time the opinion on PSA-based screening has shifted towards the notion of informed choice. Nowadays, it is thought to be unethical to screen men without them being aware of the pros and cons of PSA testing, as well as the fact that an informed choice is related to better patient outcomes. Now, as the results of three major screening studies have been presented and the downsides of screening are becoming better understood, informed choice is becoming more relevant.

Shared decision-making in the management of patients with inflammatory bowel disease

The rapid progress of research into inflammatory bowel disease(IBD)has resulted in increasingly more treatment options.Different options have different advantages and disadvantages,and the preferences of patients may also differ.If patients can be invited to the formulation of medical decision-making,their compliance and satisfaction would be improved,thus possibly achieving better therapeutic results.The present review aims to summarize the current literature on shared decision-making(SDM)in the management of IBD,with the goal of promoting the application of SDM.

The concept of narrative evidence-based medicine and shared decision-making in traditional Chinese medical practice

随着精准医疗战略的推进，新兴诊断治疗技术的爆发式发展，共同决策可以提高临床决策的质量，促进中医临床研究向证据的转化。关注患者的叙述需求，加强医学人文关怀，可提高临床疗效和患者满意度。本文介绍了循证医学、叙述医学和共同决策的起源和发展，分析了中医临床决策中存在的问题。进一步，在叙述循证医学理念和方法的指导下，提出了临床医师和患者共同决策的方法。

Preferences for participation in shared decision making of psychiatric outpatients with affective disorders

Objective: To assess preferences for participation in shared decision making in a representative sample of psychiatric outpatients with affective disorders and to understand how clinical and socio-demographic variables influence patients’ preferences for participation. Method: A cross-sectional survey of 172 consecutive psychiatric outpatients with affective disorders attending at Community Mental Health Care setting was carried out. Patients expressed preferences on each of 3 aspects of decision making (seeking information, discussing options, making the final decision). The “CGI Severity and Improvement Scales” and the “Beck Depression Inventory” scale were used for severity assessment. Additionally the “Drug Attitude Inventory”, the “Beliefs about Medicine Questionnaire” and the “Leeds Attitude toward Concordance Scale” were applied to all participants. Effects of variables considered on preferences were assessed using proportional odds regression models. Results: We registered a high response rate of 85%. Nearly all patients (91%) preferred to leave final decisions to their treating psychiatrists and 87% preferred to rely on psychiatrists for medical knowledge rather than seeking their own information. In contrast, 81% of patients preferred to be offered options and to be asked their opinion by their doctors. Gender, age, educational level, number of psychotropics used and belief about psychiatric medication overuse were significant predictors in decision making dimensions considered. Conclusion: Shared decision making approach of patients with affective disorder must take into consideration a more doctor-directed approach preferred by the patients in which the desire to be offered options is not automatically linked with the willingness of taking decisions or getting more knowledge.

Older Patients’ Involvement in Shared Decision-Making—A Systematic Review

Shared decision-making has been described as allowing patients to gain more control over their life situation and feel less helpless. The aim of this systematic review was to describe the involvement of older patients in shared decision-making in community settings. In accordance with the systematic review method, a total of 2468 abstracts were read, after which nine quantitative studies were included. A qualitative thematic analysis was performed and two themes emerged;increased understanding of self-management and a desire to strengthen one’s position in relationship with professionals, both of which were essential for empowering older patients to participate in shared decision-making. Older patients’ shared decision-making was seen as a struggle to maintain their autonomy in different areas of everyday life. Emotional and psychological problems made their position more difficult. In order to empower them in relationships with healthcare professionals, older patients require more knowledge (self-efficacy) and information about their illness, which could strengthen their position in the decision-making process. They also need a greater awareness of decisional conflicts that may arise. Age, gender and health status influence older patients’ chance of being respected and taken seriously in relationship with professionals.

Patient’s Perception of Autonomy Support and Shared Decision Making in Physical Therapy

Background: Shared Decision Making (SDM) is primarily intended to enhance patient autonomy. To date, the relationship between patients’ perceived levels of involvement and autonomy support has never been investigated in the field of physical therapy. Based on the recently reported extremely low level of observed SDM in physical therapy, similarly poor patient perceptions are expected. Objective: The main objectives of this study were to examine patients’ perceptions of SDM and autonomy support in physical therapy and to explore the relationship between both. Design: Patient survey after real consultations in physical therapy. Methods: Patients completed the Dyadic Observing Patient Involvement (Dyadic OPTION) instrument and the Health Care Climate Questionnaire (HCCQ) to examine patients’ perceived levels of SDM and autonomy support, respectively. Multilevel analyses were applied to determine the relationship between both perceptions. Results: Two hundred and twenty-nine patients, who were recruited by 13 physical therapists, agreed to participate. The median Dyadic OPTION score was 72.9 out of a total possible score of 100. The median HCCQ score was 94.3 out of a total possible score of 100. Patients’ experienced level of SDM (b = 0.14;p < 0.001) and patients’ age (b = 0.12;p = 0.001) contributed to patients’ perceived autonomy support. None of the physical therapist characteristics were related to patients’ perceived autonomy support. Limitations: Only 13 out of 125 therapists who were personally contacted agreed to participate. Conclusion: Using patients’ perceptions, we found that a relationship between SDM and autonomy support existed. In contrast to observational studies, our study also demonstrated that the participating physical therapists individually tailored patient support by adapting their implementation of SDM to each patient.

Shared Decision Making in Residential Aged Care: A Framework Synthesis

Very little is known about shared decision making (SDM) in residential aged care, despite world-wide policy and imperatives that encourage resident choice and autonomy. This paper provides a framework synthesis of SDM in residential aged care (RAC) and potential barriers and enablers to implement SDM utilising a theoretical framework of implementation. A review of the literature on SDM in RAC from 2005 to 2016 was undertaken, using MEDLINE (Ovid), CINAHL, PsychINFO and Scopus. The articles were synthesised by utilising an implementation theory framework to better understand what may facilitate or hinder the introduction of SDM. Eighteen studies were identified and analysed to determine barriers and enablers to SDM in RAC from the perspectives of staff, residents and relatives. A workplace culture of person-centred care and judicious use of research evidence are enablers of SDM. There is a potential need for additional resources, such as education for staff and families to enable implementation of SDM. Implementation of any health care intervention, including SDM, relies on many complex factors but these are predominantly related to capacity. Determining current uptake and readiness of RAC organisations, residents and their families to adopt SDM is an essential starting point.

Role of decision aids in orthopaedic surgery

Medical treatment of patients inherently entails the risk of undesired complication or side effects. It is essential to inform the patient about the expected outcomes, but also the possible undesired outcomes. The patients preference and values regarding the potential outcomes should be involved in the decision making process. Even though many orthopaedic surgeons are positive towards shared decision-making, it is minimally introduced in the orthopaedic daily practice and decision-making is still mostly physician based. Decision aids are designed to support the physician and patient in the shareddecision-making process. By using decision aids, patients can learn more about their condition and treatment options in advance to the decision-making. This will reduce decisional conflict and improve participation and satisfaction.

Decision aids can decrease decisional conflict in patients with hip or knee osteoarthritis: Randomized controlled trial

BACKGROUND The interest in shared decision making has increased considerably over the last couple of decades.Decision aids(DAs)can help in shared decision making.Especially when there is more than one reasonable option and outcomes between treatments are comparable.AIM To investigate if the use of DAs decreases decisional conflict in patients when choosing treatment for knee or hip osteoarthritis(OA).METHODS In this multi-center unblinded randomized controlled trial of patients with knee or hip OA were included from four secondary and tertiary referral centers.Onehundred-thirty-one patients who consulted an orthopedic surgeon for the first time with knee or hip OA were included between December 2014 and January 2016.After the first consultation,patients were randomly assigned by a computer to the control group which was treated according to standard care,or to the intervention group which was treated with standard care and provided with a DA.After the first consultation,patients were asked to complete questionnaires about decisional conflict(DCS),satisfaction,anxiety(PASS-20),gained knowledge,stage of decision making and preferred treatment.Follow-up was carried out after 26 wk and evaluated decisional conflict,satisfaction,anxiety,health outcomes(HOOS/KOOS),quality of life(EQ5D)and chosen treatment.RESULTS After the first consultation,patients in the intervention group(mean DCS:25 out of 100,SD:13)had significantly(P value:0.00)less decisional conflict compared to patients in the control group(mean DCS:39 out of 100,SD 11).The mean satisfaction score for the given information(7.6 out of 10,SD:1.8 vs 8.6 out of 10,SD:1.1)(P value:0.00),mean satisfaction score with the physician(8.3 out of 10,SD:1.7 vs 8.9 out of 10,SD:0.9)(P value:0.01)and the mean knowledge score(3.3 out of 4,SD:0.9 vs 3.7 out of,SD:0.6)(P value:0.01)were all significantly higher in the intervention group.At 26-wk follow-up,only 75 of 131 patients(57%)were available for analysis.This sample is too small for meaningful analysis.CONCLUSION Providing patients with an additional DA may have a positive effect on decisional conflict after the first consultation.Due to loss to follow-up we are unsure if this effect remains over time.

Blockchain-based Bank-to-Personal Credit Decisions

With the continuous integration of Internet technology and people's lives,blockchain technology provides more possibilities for the development of the banking industry.Blockchain is a distributed database.It has the characteristics of non-tampering,openness,transparency,decentralization,and good anonymity.It can well solve the shortcomings of the current personal credit evaluation system,thus proposing corresponding strategies for banks.Firstly,this paper proposes the challenges and difficulties in building a personal credit data sharing system based on blockchain,designs a personal credit data sharing model based on blockchain technology,and proposes a personal credit evaluation mechanism based on blockchain,including three parts:credit mechanism,credit index,and weighted scoring algorithm.Finally,through the linear regression model,corresponding credit strategies are proposed for banks.

Conditions for autonomous choice： a qualitative study of older adults＇ experience of decision-making in TAVR

耐心的自治是在为分享的决策的生物伦理学和一个基础的一个领先的原则。这研究为最近经历了 trans 导管的更老的成年人经验丰富的一种自治选择探索条件必要的大动脉的阀门代替(TAVR ).MethodsQualitative 学习一件有目的的样品的半结构化的会见十更旧(范围 73-89，中部 83.5 年) 在 TAVR 以后的成年人(中部 23 天) 。学习背景是在自从 2010，执行 TAVR 的一所大学医院的一个心脏的部门。当选择似乎难或不在时，分析由系统的文章 condensation.ResultsEven， TAVR 病人故意抓住了处理风险评价，矛盾心理和命运提供他们的机会。他们考虑了衰退比接受与过程有关的风险更坏的治疗。被他们的医生彻底地劝告的经验形成了自治信任的基础。他们为医生建议感到了的信任关于过程和风险减轻了矛盾心理。TAVR 病人表示了与 self-empowerment 一致的感情并且宣称它不得不是他们的决定。甚至这样，选择干预为一项义务到他们的家庭或消极地相信它也是一个自治决定的 reported.ConclusionsOlder TAVR 病人经验可以包含坦率的折衷；象一个有弹性的自我看法一样商讨医生相关性。医生们应该特别知道 how older 成年人微妙的认知衰落和倾向到当获得知情同意时，保存他们能影响他们的医药决策的身份。心脏病专家和另外的供应商可以也使用这些卓见开发更好对如此的固有的复杂性作出回应的新策略。

医患共同决策对患者家属诊疗期望值及满意度的影响

应用病例对照研究方法对拟行冠状动脉旁路移植术的患者进行医患共同决策干预。研究发现,经过医患共同决策干预的患者和家属,沟通后对诊疗结果的期望值明显减低,且沟通诊疗期望值低于传统方式沟通的患者和家属;在满意度测评中,干预组满意度和患者参与满意度调查的比例高于对照组,且干预组患者主导的满意度得分高于对照组和干预组家属主导的满意度得分。积极应用医患共同决策能够合理调控患者及其家属对诊疗行为的期望值,提升患者满意度,值得在国内医疗机构推广。

跨文化视角下我国医患共同决策的研究进展

医患共同决策是一种以患者为中心的决策模式,护士应在其中扮演重要角色。然而,不同的文化背景会对医患共同决策产生影响,医疗伦理观念和法律差异也对医患共同决策的实施提出了挑战。在中国的家庭主义传统下,实现理想的患者自主决策模式存在一定难度。基于此,文章提出未来我国护理研究应更多关注医患共同决策过程中的跨文化调试,强调医患共同决策过程中护士的参与和作用,寻找文化平衡来构建有多角色参与的中国的医患共同决策模式和工具。

晚期癌症患者基于共享决策理论的预立医疗照护计划干预

目的探讨基于共享决策理论的预立医疗照护计划干预对晚期癌症患者的实施效果。方法将107例晚期癌症患者按入院时间分为两组,2023年5-7月收治的54例患者为对照组,2023年8-10月收治的53例患者为干预组。对照组实施常规护理干预,干预组在对照组基础上实施基于共享决策理论的预立医疗照护计划干预。干预4周后,比较两组预立医疗照护计划接受度、决策参与满意度及尊严得分。结果干预后干预组预立医疗照护计划接受度总分及各维度得分、决策参与满意度总分显著高于对照组,而尊严总分显著低于对照组(均P<0.05)。结论对晚期癌症患者实施基于共享决策理论的预立医疗照护计划干预,能提高其预立医疗照护计划接受度,改善决策参与满意度,维护临终患者尊严。

叙事医学之于外科临床决策的价值思考

癌症的治疗理念和技术发展到微创和精准医学新时代,但临床决策更加复杂化。临床决策是癌症诊疗中重要环节,但传统临床决策模式无法满足癌症患者对高质量诊疗日益增长的需求,而建立在叙事医学基础上的医患共同决策是理想的决策模式。叙事医学让外科医生关注患者的故事、重现真实世界及真实需求等,构建医患信任的合作关系,让医学人文渗透到癌症外科临床决策的全过程。叙事医学融入癌症的临床诊疗过程中,有助于突破医患共同决策困境,实现叙事赋能、赋权,达成基于叙事医学的医患共同决策,但是当前仍需提升外科医生的叙事医学能力和素养,加强叙事医学本土化实践,营造优质叙事医学生态。

临床医生实践医患共同决策的思考

医患共同决策是继家长式决策模式和知情同意模式后,逐渐被大家认可的临床决策模式。在我国经历20多年的发展,逐渐被临床医生所认可并不断引入临床实践,但其发展并不如想象中那么乐观。虽然它可以改善医患关系、减少决策失误,但实际工作中仍存在缺乏政策指引、医患双方互不信任、医生没有实现共情等诸多实际问题,致使医患共同决策的推进并不顺畅。因此,医患共同决策模式作为理想的决策模式,在我国临床工作中仍需要不断探索与完善。

考虑健康信念的游客分时预约行为分析

为探索新冠肺炎疫情背景下景区分时预约策略、游客健康信念和风险预防行为之间的关系,需考虑健康信念,分析疫情防控期间游客分时预约行为机理。采用意愿调查法获取旅游信息、健康信念、分时预约行为意向数据,分析各预约时段余票比例和门票预售期等信息对游客分时预约行为的影响。基于Nested Logit(NL)模型,建立考虑健康信念的游客游玩日期-时段预约选择联合模型,并进行敏感性分析。结果表明:预约信息、健康信念对游客预约节假日或非节假日游玩有显著影响;票价、各预约时段余票比例和健康信念对游客游玩时段预约选择行为有显著影响。游客感知新冠的严重性由1上升至5时,选择节假日出行的概率由30.46%下降至12.28%。研究可为景区分时预约策略的制定提供参考依据。

共享制造环境下基于Z-RIM的QoS多方异质评价方法

为解决共享制造环境下决策信息异质、候选服务数量动态变化的制造服务QoS评价问题,基于平台、服务需求方、服务提供方的三方决策信息,提出一种符合共享制造特点的QoS多方异质制造服务评价方法。通过精确数、语言变量和Z-number处理异质信息;基于共识最大化计算决策方权重向量,利用TrFWAA算子集结多方信息,依据离差最大化模型计算属性权重;在此基础上,采用RIM对各服务进行评估。结合共享制造环境下的制造业服务优选案例对提出的方法进行验证分析,结果表明该方法具有较好的实用性和优越性。