共享决策在慢性病治疗中的应用进展——以糖尿病为例

综述了共享决策的来源及特征,共享决策实施的支持方式以及在糖尿病患者中的实施步骤和影响因素。归纳分析了共享决策在糖尿病患者中的应用效果,包括提高患者对疾病的认知、改善患者的风险感知、帮助患者控制血糖、提高患者满意度,改善决策质量。共享决策与传统的诊疗决策不同,不再是医师主导型,主要强调患者的个人偏好和价值观念在医疗决策中的作用。并探讨其存在的不足和未来发展趋向,旨在为我国糖尿病患者共享决策的开展提供理论支撑和方法借鉴。     

直觉思维在麻醉临床决策中的应用

围手术期麻醉医师面临问题的复杂性、动态性和模糊性,要求其在具备良好逻辑思维能力的同时,还要学会应用直觉思维来进行麻醉危机管理。通过决策判断的双加工理论模型探讨说明直觉思维在临床麻醉决策中的可应用性,并给出麻醉医师直觉思维的培养途径,提高麻醉医师的思考能力,增加应急处理课程和临床训练,重视临床经验的学习,营造良好的教学氛围。为了在围手术期更好地保证患者的安全,麻醉医师应重视直觉思维在临床麻醉决策中的应用。     

病人临终决策中的自主问题辨析

自主在医学伦理学中是一个重要的概念。在临终决策中,必须对病人自主从主体自主和行为自主两个维度加以区分,并强调缺乏内外部约束的重要性,尽管内部约束对病人自主影响巨大,但它并不会破坏临终决策的行为自主。在回顾两种反对将行为自主作为理解临终决策手段的意见基础上,应当实现行为自主的标准从完全自主向充分自主的转变,充分自主的优势在于它对各种医疗环境和背景条件所表现出的适应性。根据这一标准,诸如临终病人的死亡选择并不需要完全自主,充分自主即可。

     

“为癌症患者心理赋能”的临床干预路径

“为患者心理赋能”是近年来医疗健康领域出现的一种新的积极医疗照护理念,其关注点是个体的能力而非缺陷,它强调医疗实践应该为改善健康和生活质量建立患者激励结构。首先梳理了赋能的概念发展与心理结构,随后引证多个实证研究总结出为癌症患者心理赋能的四条临床干预路径,指出医患共同决策、同伴支持、赋能教育以及认知行为压力管理的赋能价值。最后结合已有成果和研究中发现的问题,提出癌症心理赋能干预发展建议,有利于进一步开展临床研究和实践探索。

     

患者决策能力与风险相关标准

患者决策能力对于患者享有临床知情同意权具有重要意义。风险相关标准主张决策所需的能力水平应该根据决策的结果来调整,单一的决策能力标准是不够的。决策结果带来的风险越大,能力水平要求越高,反之则可以要求较低的能力水平。该主张的伦理本质是不合理家长主义,并且,它意味着对同一决策任务,个体可能只有同意的能力而没有拒绝的能力,因而在经验上也站不住脚。患者决策能力标准仅应根据决策本身的复杂性和难易程度视该决策特性来决定,而独立于患者实际决策结果。     

Institutional creativity and pathologies of potential space: The modern university

Abstract

This paper proposes the applicability of object relations psychoanalytic conceptions of dialogue (Ogden, 1986 Ogden, T. 1986. The matrix of the mind, London: Karnac.  [Google Scholar], 1993 Ogden, T. 1993. “On potential space”. In In one's bones: The clinical genius of Winnicot, Edited by: Goldman, D. Northvale, NJ: Jason Aaronson.  [Google Scholar]) to thinking about relationships and relational structures and their governance in universities. It proposes that:

• the qualities of dialogic relations in creative institutions are the proper index of creative productivity; that is of, as examples, ‘thinking’ (Evans, 2004 Evans, M. 2004. Killing thinking: The death of the universities, London: Continuum.  [Google Scholar]), ‘emotional learning’ (Salzberger-Wittenburg et al., 1983 Salzberger-Wittenburg, I., Henry, G. and Osborne, E. 1983. The emotional experience of learning and teaching, London: Routledge.  [Google Scholar]) or ‘criticality’ (Barnett, 1997 Barnett, R. 1997. Higher education: A critical business, Buckingham: Open University Press.  [Google Scholar]);

• contemporary institutions' explicit preoccupation in assuring, monitoring and managing creative ‘dialogue’ can, in practice, pervert creative processes and thoughtful symbolic productivity, thus inhibiting students' development and the quality of ‘thinking space’ for teaching and research.

In this context the paper examines uncanny and perverse connections between Paulo Freire's (1972 Freire, P. 1972. Pedagogy of the oppressed, London: Penguin.  [Google Scholar]) account of educational empowerment and dialogics (from his Pedagogy of the oppressed) to the consumerist (see, for example, Clarke & Vidler, 2005 Clarke, J. and Vidler, E. 2005. Creating citizen-consumers: New labour and the remaking of public services. Public Policy and Administration, 20: 19–37.  [Google Scholar]) rhetoric of student empowerment, as mediated by some strands of managerialism in contemporary higher education. The paper grounds its critique of current models of dialogue, feedback loops, audit and other mechanisms of accountability (Power, 1997 Power, M. 1997. The Audit Society: Ritual's of verification, Oxford: Oxford University Press.  [Google Scholar]; Strathern, 2000 Strathern M. Audit cultures: Anthropological studies in accountability, ethics and the academy London Routledge 2000 [Crossref] , [Google Scholar]), in a close analysis of how creative thinking emerges.

The paper discusses the failure to maintain a dialogic space in humanities and social science areas in particular, exploring psychoanalytic conceptions from Donald Winnicott (1971 Winnicott, D. W. 1971. Playing and Reality, London: Routledge.  [Google Scholar]), Milner (1979 Milner, M. 1979. On not being able to paint, New York: International Universities Press.  [Google Scholar]), Thomas Ogden (1986 Ogden, T. 1986. The matrix of the mind, London: Karnac.  [Google Scholar]) and Csikszentmihalyi (1997 Csikszentmihalyi, M. 1997. Creativity, New York: Harper Perennial.  [Google Scholar]). Coleridge's ideas about imagination as the movement of thought between subjective and objective modes are discussed in terms of both intra- and inter-subjective relational modes of ‘dialogue’, which are seen as subject to pathology in the pathologically structured psychosocial environment. Current patterns of institutional governance, by micromanaging dialogic spaces, curtail the ‘natural’ rhythms and temporalities of imagination by giving an over-emphasis to the moment of outcome, at the expense of holding the necessary vagaries of process in the institutional ‘mind’. On the contrary, as this paper argues, creative thinking lies in sporadic emergences at the conjunction of object/(ive) outcome and through (thought) processes.     

贪婪:态度、动机与决策机制

贪婪是人性的重要特点之一,也是哲学、经济学等领域经常讨论的话题.本文首先梳理了贪婪的概念,并将问题聚焦在对于物质的贪婪上.然后总结了贪婪的特点,并提出贪婪的定义.接着阐述了情境因素如何影响个体对贪婪的态度,以及贪婪动机如何影响自利行为.贪婪决策是个体决定是否做出贪婪行为的心理过程,受到自我意识和情绪的影响.贪婪决策过程模型整合了控制性、自动化两类加工方式,阐释了自利倾向与道德自觉相互作用的机制.本文对以上内容逐次进行讨论,并提出了未来研究的方向.     

The Effects of Note-Taking and Review on Sensemaking and Ethical Decision Making

The effectiveness of case-based learning in ethics education varies widely regarding how cases are presented. Case process instruction may impact case-based ethics education to promote sensemaking processes, ethical sensemaking strategy use, and ethical decision making (EDM) quality. This study examined two teaching techniques, notes and review, and participants completed note-taking and review activities examining a case-based scenario during an ethics education course. Results suggest that providing case notes in outline form improves sensemaking processes, strategy use, and EDM quality. In addition, combining processes of provided notes and passive review results in incremental, additive performance via certain ethical sensemaking strategies and EDM quality.     

Attitudes towards credit and finances among college students in China and the United States

Although there is growing concern about the issue of credit card debt among college students in China, little research has examined attitudes to money and debt among that group. The present study compared financial self‐confidence, perceived financial wellbeing, attitudes to debt, and parent education about money and debt in 410 college students from the US and China. Although college students in China reported fewer credit cards and less debt, they also reported lower levels of financial self‐confidence and financial wellbeing. In both cultures, delay of gratification and parental education predicted both self‐confidence and financial wellbeing.     

Interests and Leadership among Adolescents

The purpose of this study was to ascertain whether there is a differential relationship in the socialization of children with respect to gender identification when responses of children were examined with respect to race and sex (N = 596 fifth and sixth grade boys and girls). Strong father preference was found to have no effect on the choice a boy will make when choosing between male and female peers, during preadolescence, while a strong mother preference by a girl is related to the sex of the peers she chooses. Preadolescent girls who identify with their mothers chose girls with whom to interact in a variety of activities more frequently than they chose boys. A greater proportion of girls preferred to engage in activities with their mothers than boys preferred to engage in activities with their fathers. No differences were observed between racial groups in terms of girls' choices involving peers. Black boys, however, preferred to engage in activities with opposite-sex rather than same-sex peers to a greater extent than white boys.