衛生福利部醫病共享決策平台
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決策輔助工具摘要表

醫師診斷為乳癌,我該先做術前前導(新輔助)化療,還是直接手術? 最新更新日期:2019年09月19日
科別 外科
主題類別 10. 腫瘤
決策類型 治療
關鍵字 乳癌、術前導 (新輔助 )化療、手術
適用病人條件 1.經切片檢驗報告確診為乳癌。 2.符合執行術前前導(新輔助)化療條件:腫瘤範圍達到2公分以上,且乳癌類型為HER-2陽性或三陰性病人。
可供選擇決策方案 先進行「術前前導(新輔助)化療」,再接受其他方式治療,乳癌手術
使用場所 診間、病房
執行者 醫師、護理師
開發團隊、機構 奇美醫療財團法人柳營醫院※本決策輔助工具由國民健康署部分經費補助
團隊成員
版本
輔助工具研發過程說明 一、界定範圍:
病人以往對於乳癌化療或手術大都遵從醫師的建議,若有疑慮時也較不會主動提出或是不知道如何, 若治療結果不盡病 人所預期,可能造成醫關係緊張、不信任。 藉由醫病共享決策, 讓病人表達 自己的想法 ,醫師 也針 對病人有疑問的地方進行解說,雙一起決策治療向使醫關係和諧達到雙贏的結果 。
二、使用者需求調查
(一)調查方式
1.乳癌多專科醫療團隊確立主題後,由主治醫師及乳癌個管師於門診、病房針對已接受乳癌治療(化療或手術)之病人,問卷方式進行質性訪談,了解她們當初在接受罹患乳癌訊息時,對於疾病治療相關的問題(需求或困難)。
2.以質性訪談乳癌相關醫療人員,將其治療方式的類型,涵蓋其醫療人員(醫師、疾病管理師)在治療說明過程中需要的訊息。
3.彙整病人端及醫療人員的需求介入後續實證文現蒐集的關鍵字串。
4.檢視病人及醫療人員端對於乳癌治療的主要需求關鍵字為下:
(1)病人端:
A.乳癌是什麼、會有什麼症狀?
B.有哪些治療方式?
C.有哪些手術方式?
D.手術前先化療或直接手術的優缺點?
E.有沒有什麼合併症?
F.手術後傷口的復原時間長短?
(2)醫療人員端
A.病人常問的問題有:疾病症狀、嚴重性、治療方式、優缺點、合併症、癒後、
是否自費等。
B.術前前導(新輔助)化療能否檢測化療藥物的敏感性?
C.術前前導(新輔助)化療療程需多久時間?
D.術前前導(新輔助)化療的介紹
E.手術類型的介紹
5.計訪談5位乳癌病人及5位醫療人員(醫師4位、疾病管理師1人)。
三、實證資料
經檢視美國NCCN Guideline及3篇領域文獻後,確立其病人及醫療人員的問題解答,續將彙整於決策輔助工具內容。
四、測試與修訂
(一)歷經團隊確立主題後,以開放式題項進行需求評估,訪談先前已完成乳癌手術治療或術前前導(新輔助)化療的病人,進行質性訪談;其病人端提出的6項特別在意的問題;並訪談院內醫療照護團隊(主治醫師及疾病管理師),針對乳癌治療方式(前導新輔助化療及手術)說明,進行需求彙整。
(二)研發團隊以實證PICO歷程進行資料庫搜尋後,溶入臨床專科醫師治療經驗作法,其中並考量院內醫療環境及團隊共識後,完成第一版決策輔助工具表設計。
(三)α test質性建議及處理流程
1.於將已完成的第一版決策輔助表,提供給另一群已完成乳癌手術治療或術前前導(新輔助)化療的病人及另一群醫療照護團隊成員(主治醫師及疾病個案管理師、護理師),進行決策輔助表內容的簡化作業,研發出圖像式輔助工具(PDAs)-初擬版。
(四)βtest質性建議及處理流程
1.將第一版圖像式輔助工具(PDAs)列入乳癌多醫療專科團隊進行討論,續委請科部代表(一般外科及血液腫瘤科)於次專科會議宣導,於門診診間針對收案條件(初診乳癌患者且腫瘤大小為大於2公分以上,且病理檢驗報告為HER2+或三陰性)進行病人端試行。
2.依據乳癌輔助工具作業流程及參酌SHARE Approach步驟,在醫師判定合適個案後,會先簡述疾病現況及術前前導(新輔助)概念;續由疾病個案管理師進行內容說明,並請病人回覆簡要問題後(回覆確認)。
3.最後再將決策輔助決策輔助工具(B5紙本及QRCode紙單)攜回與家人進行討論。疾病個案管理師在訪談個案後,在以「輔助工具建議單-病人版」委請病人及家屬回饋建議,務必真實答覆輔助工具的優劣及改善建議事項。
4.在圖像式輔助工具(PDAs)-初擬版設計後,隨即委請乳癌多專科醫療團隊成員,填答「輔助工具建議單-員工版」委請院內同仁回饋改善建議事項。
5.醫療團隊及病人家屬單回饋建議,即作為圖像式輔助工具(PDAs)-定稿版的建議。
(五)圖像式輔助工具(PDAs)-定稿版
1.歷經乳癌多專科醫療團隊會議討論後,確立「圖像式輔助工具(PDAs)-定稿版」,並經癌症委員會進行宣告於門診實施。

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