美国《临床肿瘤杂志》2017年9月11日在线先发

http://ascopubs.org/doi/full/10.1200/JCO.2017.75.2311

医患沟通：《美国临床肿瘤学会》共识指南

目的

为改善医患关系、优化医生患者和家人满意度，就如何进行有效的沟通向肿瘤医生提供指导。

方法

ASCO召集了一个由肿瘤学、精神病学、护理、临终关怀和姑息治疗、沟通技巧、卫生差异和健康宣教方面的专家组成的多学科专家组，提出推荐建议。指南的制定涉及对文献的系统复习和达成正式共识的过程。对文献的系统复习侧重于2006年至2016年10月1日发表的指南、综述和荟萃分析以及随机对照试验。

结果

对文献的系统复习纳入了47篇发表的文献。除了临床医生的沟通技巧培训外，许多临床问题的证据有限。定稿前，对推荐建议草案进行了两轮共识投票。

建议

除了为全程癌症治疗提供核心沟通技巧和沟通任务的指导以外，推荐建议还涉及到具体议题，如探讨治疗和预后目标、治疗选择、终末期治疗、鼓励家人参与治疗和临床医师的沟通技巧培训。推荐建议还伴有建议的实施策略。有关更多信息，请访问网站www.asco.org/supportive-care-guidelines和www.asco.org/guidelineswiki。

《桓兴医讯》田丽霞

完善的医疗沟通可以改善许多主、客观健康指标，这些指标包括血压的控制、糖尿病的糖化血红蛋白、药物使用的依从性以及患者满意度。在肿瘤临床医疗过程中，沟通（包括肿瘤的化疗、放疗、手术）有众多挑战。医生往往必须告知病人和家属灾难性消息，癌症是可怕的疾病，病人可能会对诊断和治疗信息产生恐惧、悲伤、否认或愤怒。这些强烈的情绪可能会使医生不舒服，但限定在临床实践过程中，医生必须学会给病人以支持、帮助病人面对疾病，必须有效地建立和谐融洽的关系，给患者传递充分的信息，解释病人和家人所关心的问题。癌症还是一类复杂的疾病，常常需要复杂的治疗，大多数病人的教育背景难以帮助他们了解癌症的诊断和治疗，而许多医生缺乏训练，并没有准备好以病人和其它非专业人员理解并记住的方式传递有关复杂健康问题的信息。

良好的人际沟通技巧并不能替代强有力的医患沟通技能。本指南为肿瘤医生就如何有效沟通提供指导，以改善医患关系、优化病人的治疗，提高医生、病人和亲人的满意度。该指南还涉及到有效沟通技能训练的重要环节，提出了改善医患沟通的具体实用框架。过去，通常视沟通技巧为天生的，或者是人们通过角色模型的模仿而获得，所以在很大程度上，医生只是简单地希望自己解决，但研究表明，精心设计的培训项目可以提高医生的沟通技巧、改善患者体验。肿瘤学富有挑战性的交谈有许多方式，类似于复杂的治疗流程或操作，需要采用高明的策略，精心准备、认真执行，以达到最佳的沟通效果。基于文献，这项医患沟通指南在癌症诊疗情形中，为与患者和家人的沟通提供了推荐建议和策略。

《桓兴医讯》孟祥志

重要的推荐建议

·1. 核心沟通技巧

（推荐类型：正式共识，推荐强度：强推荐）

o1.1. 每次谈话前，医生应当复习患者医疗信息，确定谈话目标、预料患者及家人的需求和反应

o1.2. 与患者谈话开始时，医生应当了解患者对所患疾病的理解情况，询问完患者及家人希望告知和解释的内容同时也是医生希望告知的内容后，与患者共同设定一个沟通议程。

o1.3. 在患者就诊期间，医生应当付诸行动，积极培养患者的信任、自信和配合。

o1.4. 医生应当提供患者感兴趣的适时信息和偏好信息。提供信息后，医生应当了解患者的理解情况、并在医疗文书中记录所讨论的重要事项。

o1.5. 当患者通过语言或非语言行的行为表达情感时，医生应当有共情性回应。

·2. 探讨治疗和预后目标

（推荐类型：正式共识，推荐强度：强推荐）

o2.1. 医生应当根据患者的需要提供诊断和预后信息、予以希望和安慰，但不误导患者。

o2.2. 当考虑对患者的治疗进行明显调整时，医生应当重新评价患者目标、患者的当务之急和所渴望的信息。

o2.3. 医生应当用简明扼要的词语提供信息。

o2.4. 提供坏消息时，医生应当采取进一步措施告知患者需求和反应。

·3. 探讨治疗选项和临床试验

（推荐类型：正式共识，推荐强度：强推荐）

o3.1. 在与患者探讨具体的治疗选项前，医生应当阐明治疗的目的（根治还是延长生存期还是改善生活质量），以便患者理解可能的结局、将治疗目标与患者所希望的治疗目标能够达成一致。

o3.2. 当与患者一起梳理治疗选项时，医生应当提供潜在的益处和治疗负担（自付比例）的信息，确定患者理解了这些益处和负担。

o3.3. 医生应当用让患者抱有希望、让患者自主决定、有助于患者理解的方式与患者探讨治疗选项。

o3.4. 医生应当让患者理解所有治疗选项，包括临床试验以及重中之重的姑息治疗。医生应当在合适的时候探讨启动姑息治疗这一选项，并与其它治疗方法同步进行。如果能够参加临床试验，医生应当与现有的临床试验以外的标准治疗一同开始进行治疗探讨，如果患者感兴趣，然后将讨论转移到申请参加临床试验上来。

·4. 探讨终末期治疗

（推荐类型：正式共识，推荐强度：强推荐）

o4.1. 医生应当采用一种组织架构指导与患者、家人有关终末期治疗的双向沟通。

o4.2. 医生应当在肿瘤不可治愈的阶段开始就患者终末期偏好选择及早会谈，基于临床事件或患者偏好，定期反复告知这一话题。

o4.3. 医生应当了解患者的文化、宗教和精神信仰是如何影响其终末期决定或治疗偏好。

o4.4. 医生应当认识到患者、家人及医生他们自己的悲伤和失落，并应当有共情性回应。医生应当在适当的时候，将患者和家人转诊到社会心理团队成员（如社工、咨询辅导员、心理医生、精神科医生以及神职人员）。

o4.5. 医生应当寻找并建议当地的资源，为过渡到终末期治疗的患者、家人和亲人提供强大支持。

·5. 采用沟通促进家人参与治疗

（推荐类型：正式共识，推荐强度：强推荐）

o5.1. 医生应当建议家人和/或看护人及早参与疾病支撑过程中的讨论（要有患者的知情同意）和治疗目标的探讨。

o5.2. 在治疗的重要节点上，确定是否应当在医院或门诊进行一次正式的家庭会议。可能的话，要确保患者、患者指定的代理人和所需的医学专业人员在场。

·6. 沟通障碍时的有效沟通

（推荐类型：正式共识，推荐强度：强推荐）

o6.1. 对于与医生不能讲同一种语言的家人，要使用医学翻译而不是由一名家人来翻译。

o6.2. 对于健康状况差的患者，聚焦最重要的要点、使用大白话并不断确认是否理解。

o6.3. 对于计算能力差的患者，采用可用的图示或其它视觉教具，告知绝对风险而不是相对风险。

·7. 探讨医疗花费

（推荐类型：正式达成的共识，推荐强度：强推荐）

o7. 医生应当了解癌症患者的医疗花费是否有问题。

·8. 满足服务不足人群的需求

（推荐类型：正式共识，推荐强度：强推荐）

o8.1. 对临床上所遇到的问题要有好奇心，要记住任何患者和家人，不论其背景如何，都可能与医生有不同的信仰、经历和期望。

o8.2. 当探讨性和性行为时，避免对性取向和性别认同的臆断，避免歧视性语言。

o8.3. 要记住服务不足或边缘化人群既往有负面就医经历的可能性会增加，这些负面经历包括感到不被尊重、被疏远、不安全感。

·9. 医生沟通技巧的训练

（推荐类型：有循证依据，证据质量：中等，推荐强度：强推荐）

o9.1. 沟通技巧训练应当基于健全的教育原则，沟通技巧训练包括并强调技能实践、采用情景角色扮演进行体验式学习、接触患者时的直接观察以及其它有效的技术。

o9.2. 执业医师必须要意识到自己对患者的情感、态度和自身的信仰以及自己对待疾病的理念等等都会影响到治疗决策，意识到这一点，才能使医患关系沟通技巧的培训最为行之有效。

o9.3. 进行沟通技巧培训的辅导人员自身应当有充分的训练和经验，以有效地对所需要的沟通技巧进行教学并做出表率，使经验性学习和训练能力得到提高。

《壹篇》李晓爽

http://ascopubs.org/doi/full/10.1200/JCO.2017.75.2311

Patient-Clinician Communication: American Society of Clinical Oncology Consensus Guideline

Purpose

To provide guidance to oncology clinicians on how to use effective communication to optimize the patient-clinician relationship, patient and clinician well-being, and family well-being.

Methods

ASCO convened a multidisciplinary panel of medical oncology, psychiatry, nursing, hospice and palliative medicine, communication skills, health disparities, and advocacy experts to produce recommendations. Guideline development involved a systematic review of the literature and a formal consensus process. The systematic review focused on guidelines, systematic reviews and meta-analyses, and randomized controlled trials published from 2006 through October 1, 2016.

Results

The systematic review included 47 publications. With the exception of clinician training in communication skills, evidence for many of the clinical questions was limited. Draft recommendations underwent two rounds of consensus voting before being finalized.

Recommendations

In addition to providing guidance regarding core communication skills and tasks that apply across the continuum of cancer care, recommendations address specific topics, such as discussion of goals of care and prognosis, treatment selection, end-of-life care, facilitating family involvement in care, and clinician training in communication skills. Recommendations are accompanied by suggested strategies for implementation. Additional information is available at www.asco.org/supportive-care-guidelines and www.asco.org/guidelineswiki.

Improved health care communication has been associated with improvements in many different objective and subjective health outcomes, including blood pressure control, hemoglobin A1C in diabetes, adherence to medication use, and patient satisfaction.1-6 Communication in oncology practice (including medical, radiation, and surgical oncology) presents numerous challenges. Clinicians often must share devastating news with patients and families. Cancers are frightening diseases, and patients may react to diagnostic and treatment information with fear, grief, denial, or anger. These strong emotions may make clinicians uncomfortable. Clinicians must learn to support patients and to help them cope and must efficiently build rapport, convey adequate information, and address patient and family concerns within the time constraints of clinical practice. Cancer is also a complicated set of diseases with often complex treatments. Most patients have little in their educational background to help them understand their cancer diagnosis and treatment. Many clinicians have received scant training to prepare them to deliver information about complex health issues in a manner that results in comprehension and retention by patients and other nonexperts.

Good interpersonal skills are not a substitute for strong health care communication skills. This guideline provides guidance to oncology clinicians on how to communicate effectively so as to optimize the patient-clinician relationship, patient care, and the well-being of clinicians, patients, and their loved ones. It also touches on key aspects of effective communication skills training. The guideline presents a framework of specific practices that improve communication. In the past, communication skills were often viewed as innate or else as something people acquired by mimicry of role models. To a large extent, clinicians were simply expected to figure it out on their own. But research suggests that well-designed training programs can improve clinicians’ communication skills and patient experience.4,7 Challenging conversations in oncology are in many ways akin to complex interventional procedures or operations in that they require careful planning and execution, using well-developed strategies to facilitate optimal communication. This guideline on patient-clinician communication provides recommendations and strategies, based on the literature, for communication with patients and families in the cancer care environment.

Key Recommendations

·1. Core communication skills

(Type of recommendation: formal consensus; Strength of recommendation: strong)

o1.1. Before each conversation, clinicians should review the patient’s medical information, establish goals for the conversation, and anticipate the needs and responses of the patient and family.

o1.2. At the beginning of conversations with patients, clinicians should explore the patient’s understanding of their disease and collaboratively set an agenda with the patient after inquiring what the patient and family wish to address and explaining what the clinician wishes to address.

o1.3. During patient visits, clinicians should engage in behaviors that actively foster trust, confidence in the clinician, and collaboration.

o1.4. Clinicians should provide information that is timely and oriented to the patient’s concerns and preferences for information. After providing information, clinicians should check for patient understanding and document important discussions in the medical record.

o1.5. When patients display emotion through verbal or nonverbal behavior, clinicians should respond empathically.

·2. Discussing goals of care and prognosis

(Type of recommendation: formal consensus; Strength of recommendation: strong)

o2.1. Clinicians should provide diagnostic and prognostic information that is tailored to the patient’s needs and that provides hope and reassurance without misleading the patient.

o2.2. Clinicians should reassess a patient’s goals, priorities, and desire for information whenever a significant change in the patient’s care is being considered.

o2.3. Clinicians should provide information in simple and direct terms.

o2.4. When providing bad news, clinicians should take additional steps to address the needs and responses of patients.

·3. Discussing treatment options and clinical trials

(Type of recommendation: formal consensus; Strength of recommendation: strong)

o3.1. Before discussing specific treatment options with the patient, clinicians should clarify the goals of treatment (cure v prolongation of survival v improved quality of life) so that the patient understands likely outcomes and can relate the goals of treatment to their goals of care.

o3.2. When reviewing treatment options with patients, clinicians should provide information about the potential benefits and burdens of any treatment (proportionality) and check the patient's understanding of these benefits and burdens.

o3.3. Clinicians should discuss treatment options in a way that preserves patient hope, promotes autonomy, and facilitates understanding.

o3.4. Clinicians should make patients aware of all treatment options, including clinical trials and a sole focus on palliative care. When appropriate, clinicians should discuss the option of initiating palliative care simultaneously with other treatment modalities. If clinical trials are available, clinicians should start treatment discussions with standard treatments available off trial and then move to a discussion of applicable clinical trials if the patient is interested.

·4. Discussing end-of-life care

(Type of recommendation: formal consensus; Strength of recommendation: strong)

o4.1. Clinicians should use an organized framework to guide the bidirectional communication about end-of-life care with patients and families.

o4.2. Clinicians should initiate conversations about patients’ end-of-life preferences early in the course of incurable illness and readdress this topic periodically based on clinical events or patient preferences.

o4.3. Clinicians should explore how a patient’s culture, religion, or spiritual belief system affects their end-of-life decision making or care preferences.

o4.4. Clinicians should recognize and respond empathically to grief and loss among patients, families, and themselves. Clinicians should refer patients and families to psychosocial team members (eg, social workers, counselors, psychologists, psychiatrists, and clergy) when appropriate.

o4.5. Clinicians should identify and suggest local resources to provide robust support to patients, families, and loved ones transitioning to end-of-life care.

·5. Using communication to facilitate family involvement in care

(Type of recommendation: formal consensus; Strength of recommendation: strong)

o5.1. Clinicians should suggest family and/or caregiver involvement in discussions (with patient consent) early in the course of the illness for support and discussion about goals of care.

o5.2. Determine if a formal family meeting in a hospital or outpatient setting is indicated at important junctures in care. When possible, ensure that patients, their designated surrogates, and desired medical professionals are present.

·6. Communicating effectively when there are barriers to communication

(Type of recommendation: formal consensus; Strength of recommendation: strong)

o6.1. For families who do not share a common language with the clinician, use a medical interpreter rather than a family interpreter.

o6.2. For patients with low health literacy, focus on the most important points, use plain language, and check frequently for understanding.

o6.3. For patients with low health numeracy, use pictographs or other visual aids when available, and describe absolute risk rather than relative risk.

·7. Discussing cost of care

(Type of recommendation: formal consensus; Strength of recommendation: strong)

o7. Clinicians should explore whether cost of care is a concern for patients with cancer.

·8. Meeting the needs of underserved populations

(Type of recommendation: formal consensus; Strength of recommendation: strong)

o8.1. Enter clinical encounters with a sense of curiosity, aware that any patient and family, regardless of their background, may have beliefs, experiences, understandings, and expectations that are different from the clinician’s.

o8.2. Avoid assumptions about sexual orientation and gender identity and use nonjudgmental language when discussing sexuality and sexual behavior.

o8.3. Remain aware that members of underserved or marginalized populations have an increased likelihood of having had negative past health care experiences, including feeling disrespected, alienated, or unsafe.

·9. Clinician training in communication skills

(Type of recommendation: evidence based; Quality of evidence: intermediate; Strength of recommendation: strong)

o9.1. Communication skills training should be based on sound educational principles and include and emphasize skills practice and experiential learning using role-play scenarios, direct observation of patient encounters, and other validated techniques.

o9.2. For communication skills training to be most effective, it should foster practitioner self-awareness and situational awareness related to emotions, attitudes, and underlying beliefs that may affect communication as well as awareness of implicit biases that may affect decision making.

o9.3. Facilitators of communication skills training should have sufficient training and experience to effectively model and teach the desired communication skills and facilitate experiential learning exercises.

《壹篇》（与桓兴医讯同步）系主要面向医务人员的公益性头条号，不以营利为目的，不进行任何有偿咨询和服务，不出售任何产品，与ASCO、CSCO等所有专业学会和机构没有任何关系和联系，也不代表任何官方学会发声。

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