Surrogate Decision Making

许多患者无法自己做出医疗决定（Raymont V, et al . 2004; Silveira MJ, et al . 2010）。目前的临床实践依赖于临床医生和代理人之间的共同决策来为这些患者做出治疗决定。这一决策过程旨在促进符合患者自身偏好和价值观的医疗服务。然而，经验数据表明，这种方法面临两个重大挑战。首先，代理人和临床医生很难预测患者会选择哪种治疗方案。其次，代孕母亲在做出治疗决定后，往往会经历严重的情绪困扰。为了解决这些问题，有人建议，共同决策过程可能会辅以患者偏好预测器（PPP）。购买力平价将根据类似患者在类似情况下的治疗偏好，预测特定患者想要哪种治疗。其他信息可以从患者自己的医疗记录以及他们的在线活动中获得。初步研究表明，将PPP纳入共同决策过程可能有助于提高医疗决策反映决策丧失能力患者偏好的程度，并减轻代理人和临床医生感受到的一些情绪负担。我们对患者进行的一项调查发现，如果使用PPP会提高共享决策过程的预测准确性，那么大多数患者认为将其纳入共享决策过程将是有益的（Rid et al, 2014）。基于这些发现，本研究采访了曾参与为无行为能力患者做决定的代理人，以探讨他们对购买力平价的看法以及如何将其纳入医疗决策。在过去的一年里，我们完成了代理人的招募，目前正在分析数据和起草手稿。初步研究结果表明，代孕母亲和患者一样，在很大程度上支持使用PPP。然而，研究结果也表明，将有两个重要的挑战需要解决。首先，一些代理人表示，他们的决定是基于他们认为最符合患者医疗利益的决定，而不是基于患者会为自己做出的决定。第二，代理人表示，他们应该对做出的决定有最终决定权。这些发现与我们小组之前的研究结果相矛盾，即患者认为他们自己的治疗偏好和价值观应该决定他们在丧失决策能力期间接受何种治疗。在未来的工作中，我们计划考虑如何解决这种紧张关系。

Many patients are unable to make medical decisions for themselves (Raymont V, et al 2004; Silveira MJ, et al 2010). Current clinical practice relies on shared decision-making between clinicians and surrogates to make treatment decisions for these patients. This decision-making process is meant to promote medical care that accords with the patients own preferences and values. However, empirical data suggest that this approach faces two significant challenges. First, surrogates and clinicians have trouble predicting which treatment course patients would have chosen. Second, surrogates often experience significant emotional distress as a result of making treatment decisions. To address these concerns, it has been suggested that the shared decision-making process might be supplemented with a Patient Preference Predictor (PPP). A PPP would provide a prediction of which treatment a given patient would want based on the treatment preferences of similar patients in similar circumstances. Additional information might be obtained from patient's own medical records, as well as their on-line activities. Preliminary research suggests that incorporating a PPP into the shared decision-making process might help to improve the extent to which medical decisions reflect the preferences of decisionally incapacitated patients and alleviate some of the emotional burden felt by surrogates and clinicians. A survey of patients that we conducted found that, if the use of the PPP would increase the predictive accuracy of the shared decision-making process, a majority of patients believe that incorporating it into the shared decision-making process would be beneficial (Rid et al, 2014). Based on these findings, the present study interviewed surrogates who have been involved in making decisions for an incapacitated patient to explore their perspectives on the PPP and how to incorporate it into medical decision-making. Over the past year, we completed the recruitment of surrogates and are currently analyzing the data and drafting manuscripts. The preliminary findings suggest that surrogates, like patients, are largely supportive of the use of a PPP. However, the findings also suggest that there will be two important challenges to address. First, a number of surrogates indicated that they make decisions based on what they think is in the best medical interests of the patient, not based on what decision the patient would have made for themselves. Second, surrogates indicated that they should have the final say in what decisions are made. These findings are in tension with previous findings from our group that patients believe their own treatment preferences and values should determine which treatments they receive during periods of decisional incapacity. In future work, we plan to consider how to address this tension.