Surrogate Decision Making

许多患者无法为自己做出医疗决定(Raymont V等人，2004年；Silveira MJ等人，2010年)。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个疗程。其次，代孕者经常因为做出治疗决定而经历重大的情绪痛苦。本项目的目标是找出解决这些关切的方法，从而改进代孕决策。我们建议用患者偏好预测值(PPP)来补充共享决策的过程。购买力平价将根据类似情况下类似患者的治疗偏好，预测给定患者将需要哪种治疗。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，将购买力平价纳入共享决策过程可能有助于改善医疗决策在一定程度上反映被判定为无行为能力的患者的偏好，并减轻他们的代理人和临床医生经历的一些情感负担。我们对患者进行的一项调查发现，如果PPP的使用将增加共享决策过程的预测准确性，大多数患者认为将其纳入共享决策过程将是有益的(RID等人，2014)。基于这些发现，我们采访了参与为无行为能力患者做出决定的代孕者，以探索他们对PPP的看法以及如何将其纳入医疗决策。这项研究发现，代孕者和患者一样，在很大程度上支持使用PPP。然而，调查结果也表明，将有两个重要的挑战需要解决。首先，一些代孕者表示，他们做出决定的基础是他们认为对患者最有利的医疗利益，而不是患者会为自己做出什么决定。其次，代理人表示，他们应该对做出什么决定拥有最终决定权。这些发现与我们小组之前的发现相矛盾，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决定性丧失能力期间接受哪些治疗。在今后的工作中，我们计划考虑如何解决这一紧张局势。

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 patient's 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. The goal of the present project is to identify ways to address these concerns and, thereby, improve surrogate decision-making. We have proposed to supplement the process of shared decision-making 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 the 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 experienced by their 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, we 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. This study found 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.