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Article(id=1322936856698036381, tenantId=1146029695717560320, journalId=1220038315760373764, issueId=1322936785516503921, articleNumber=null, orderNo=null, doi=10.12102/j.issn.1009-6493.2026.11.016, pmid=null, cstr=null, oa=null, hot=null, price=null, onlineType=0, articleFormat=0, articleType=null, articleTypeStr=null, receivedDate=1753632000000, receivedDateStr=2025-07-28, revisedDate=1772899200000, revisedDateStr=2026-03-08, acceptedDate=null, acceptedDateStr=null, onlineDate=1793342325615, onlineDateStr=2026-10-30, pubDate=1781020800000, pubDateStr=2026-06-10, doiRegisterDate=null, doiRegisterDateStr=null, onlineIssueDate=1793342325615, onlineIssueDateStr=2026-10-30, onlineJustAcceptDate=null, onlineJustAcceptDateStr=null, onlineFirstDate=null, onlineFirstDateStr=null, sourceXml=null, magXml=null, createTime=1793342325615, creator=13701087609, updateTime=1793342325615, updator=13701087609, issue=Issue{id=1322936785516503921, tenantId=1146029695717560320, journalId=1220038315760373764, year='2026', volume='40', issue='11', pageStart='1809', pageEnd='2000', issueExtLink='null', onlineDate='null', pubDate='1781020800000', pubDateStr='2026-06-10', beforeIssueId=null, nextIssueId=null, price=null, status=1, issueComplete=1, articleOrder=1, issueType=-1, specialIssue=null, createTime=1793342308644, creator='13701087609', updateTime=1793343121351, updator='13701087609', preIssue=null, nextIssue=null, articleTotal=null, ext={EN=IssueExt(id=1322940194344796237, tenantId=1146029695717560320, journalId=1220038315760373764, issueId=1322936785516503921, language=EN, specialIssueTitle=, coverIllustrator=null, specialIssueEditor=, specialIssueAbout=), CN=IssueExt(id=1322940194344796238, tenantId=1146029695717560320, journalId=1220038315760373764, issueId=1322936785516503921, language=CN, specialIssueTitle=, coverIllustrator=null, specialIssueEditor=, specialIssueAbout=)}, issueFiles=null, downloadFileDto=null}, startPage=1925, endPage=1933, ext={EN=ArticleExt(id=1322936856911945886, articleId=1322936856698036381, tenantId=1146029695717560320, journalId=1220038315760373764, language=EN, title=Qualitative study on the influencing factors of doctor-patient shared decision-making in ICU terminally ill patients, columnId=1220689488284668633, journalTitle=Chinese Nursing Research, columnName=Comprehensive Study, runingTitle=null, highlight=null, articleAbstract=
Objective

To systematically analyze the influencing factors of doctor-patient decision-making for terminally ill patients in the intensive care unit(ICU) based on the consolidated framework for implementation research(CFIR),so as to provide a basis for constructing localized nursing practice strategies.

Methods

Using purposive sampling method,a total of 28 medical staff in the intensive care unit and 12 family members of terminally ill patients from a tertiary grade A hospital in Sichuan province were selected for semi-structured interviews from March to June 2024.Directed content analysis combined with CFIR was used for coding analysis and rating.

Results

Four core themes are identified:the characteristics of shared decision-making sources of shared decision-making,relative advantages of shared decision-making,complexity of shared decision-making,costs of shared decision-making),external factor domains(local perspectives,local conditions,policies and regulations,external pressures),internal factor domains(structural features,culture,innovation incentive mechanisms,available resources,knowledge and information acquisition),and individual characteristics(needs,capabilities,opportunities,motivation).The rating identified 13 barrier factors,3 facilitating factors,and 1 neutral factor.

Conclusions

The implementation of shared decision-making is influenced by multiple dimensions,such as culture,policies,resources,and capabilities.It is urgent to establish localized shared decision-making implementation strategies,develop decision-support tools for family members,and jointly reform medical insurance,ethics,and legal policies to improve the quality of end-of-life decision-making.

, authors=Weiwei ZHOU1, Huangxin ZHANG1, Mengjie LIU2, Lan LIU3, Hao WEI3, authorsList=Weiwei ZHOU, Huangxin ZHANG, Mengjie LIU, Lan LIU, Hao WEI, authorCompany=null, correspAuthors=Mengjie LIU, authorNote=null, correspAuthorsNote=null, copyrightStatement=null, copyrightOwner=null, extLink=null, articleAbsUrl=null, sourceXml=null, magXml=null, pdfUrl=null, pdf=null, pdfFileSize=null, pdfExtLink=null, richHtmlUrl=null, mobilePdfUrl=null, reviewReport=null, pdfFirstPage=null, abstractGraph=null, abstractGraphContent=null, abstractVideo=null, citation=null, cebUrl=null, magXmlContent=null, mapNumber=null, fund=null), CN=ArticleExt(id=1322936858153459871, articleId=1322936856698036381, tenantId=1146029695717560320, journalId=1220038315760373764, language=CN, title=ICU临终病人医患共同决策影响因素的质性研究, columnId=1220689488938980091, journalTitle=护理研究, columnName=综合研究, runingTitle=null, highlight=null, articleAbstract=
目的

基于实施性研究综合框架（CFIR）系统分析重症监护室（ICU）临终病人医患共同决策的影响因素，为构建本土化护理实践策略提供依据。

方法

采用目的抽样法，于2024年3月—6月选取四川省某三级甲等医院28名重症监护室医务人员、12名重症监护室临终病人家属进行半结构式访谈，运用定向内容分析法结合CFIR进行编码分析并评级。

结果

共映射出4个主题：共同决策的特征（共同决策的来源，共同决策的相对优势，共同决策的复杂性，共同决策的费用）、外部因素领域（当地看法，当地条件，政策与法规，外部压力）、内部因素领域（结构特征，文化，创新激励机制，可用资源，知识和信息获取）、个体领域（需求，能力，机会，动力）。评级确定了13个障碍因素、3个促进因素及1个中性因素。

结论

医患共同决策的实施受文化、政策、资源及能力等多维度的交互影响，亟须构建本土化共同决策实施策略、开发家属决策支持工具及联动改革医保、伦理法律政策，以提升临终决策质量。

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周微微，硕士研究生

, correspAuthorsNote=
刘梦婕，E-mail：
LIU Mengjie, E-mail:
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pageStart=843, pageEnd=852, url=null, language=null, rfNumber=20, rfOrder=19, authorNames=杨林宁, 郑红颖, 徐于睿, journalName=中国全科医学, refType=null, unstructuredReference=杨林宁,郑红颖,徐于睿,等.医生参与医患共享决策行为特征的混合方法研究[J].中国全科医学,2023,26(7):843-852., articleTitle=医生参与医患共享决策行为特征的混合方法研究, refAbstract=null), Reference(id=1322936875115225324, tenantId=1146029695717560320, journalId=1220038315760373764, articleId=1322936856698036381, doi=null, pmid=null, pmcid=null, year=2023, volume=21, issue=9, pageStart=1285, pageEnd=1288, url=null, language=null, rfNumber=21, rfOrder=20, authorNames=黄桃英, journalName=全科护理, refType=null, unstructuredReference=黄桃英.ICU病人家属共享决策参与能力现状及影响因素分析[J].全科护理,2023,21(9):1285-1288., articleTitle=ICU病人家属共享决策参与能力现状及影响因素分析, refAbstract=null), Reference(id=1322936875182334189, tenantId=1146029695717560320, journalId=1220038315760373764, articleId=1322936856698036381, doi=null, pmid=null, pmcid=null, year=2024, volume=5, issue=6, pageStart=506, pageEnd=512, url=null, language=null, rfNumber=22, 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country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=3Southwest Medical University), AuthorCompanyExt(id=1322936860904923304, tenantId=1146029695717560320, journalId=1220038315760373764, articleId=1322936856698036381, companyId=1322936860678430886, language=CN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=3西南医科大学)])], figs=[ArticleFig(id=1322936870656680145, tenantId=1146029695717560320, journalId=1220038315760373764, articleId=1322936856698036381, language=EN, label=Table 1, caption=

General information of ICU medical staff(n=28)

, figureFileSmall=null, figureFileBig=null, tableContent=
编号性别年龄（岁）婚姻状况学历工作年限（年）职称职业
N1女32已婚本科8护师护士
N2男31未婚硕士研究生4医师医生
N3女38已婚博士研究生8主治医师医生
N4女40已婚硕士研究生16副主任护师护士
N5男28已婚硕士研究生3护师护士
N6女35已婚本科13护师护士
N7男33已婚硕士研究生6主治医师医生
N8女42已婚本科23副主任护师护士
N9女36已婚本科13主管护师护士
N10女29未婚硕士研究生3医师医生
N11男37已婚硕士研究生10主治医师医生
N12女33已婚专科12护师护士
N13男41已婚硕士研究生16副主任医师医生
N14女38已婚本科17主管护师护士
N15男36已婚硕士研究生10主治医师医生
N16女32已婚本科8护师护士
N17女53已婚硕士研究生35主任护师护士
N18女32已婚本科9护师护士
N19女31未婚硕士研究生4医师医生
N20女51已婚本科31副主任护师护士
N21女32已婚专科11护师护士
N22女41已婚本科19主管护师护士
N23男46已婚硕士研究生21主任医师医生
N24男31已婚硕士研究生6医师医生
N25女31未婚专科10护师护士
N26男41已婚本科18主管护师护士
N27女37已婚博士研究生8主治医师医生
N28男33已婚硕士研究生7医师医生
), ArticleFig(id=1322936870967058642, tenantId=1146029695717560320, journalId=1220038315760373764, articleId=1322936856698036381, language=CN, label=表1, caption=

重症监护室医务人员一般资料（n=28）

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编号性别年龄（岁）婚姻状况学历工作年限（年）职称职业
N1女32已婚本科8护师护士
N2男31未婚硕士研究生4医师医生
N3女38已婚博士研究生8主治医师医生
N4女40已婚硕士研究生16副主任护师护士
N5男28已婚硕士研究生3护师护士
N6女35已婚本科13护师护士
N7男33已婚硕士研究生6主治医师医生
N8女42已婚本科23副主任护师护士
N9女36已婚本科13主管护师护士
N10女29未婚硕士研究生3医师医生
N11男37已婚硕士研究生10主治医师医生
N12女33已婚专科12护师护士
N13男41已婚硕士研究生16副主任医师医生
N14女38已婚本科17主管护师护士
N15男36已婚硕士研究生10主治医师医生
N16女32已婚本科8护师护士
N17女53已婚硕士研究生35主任护师护士
N18女32已婚本科9护师护士
N19女31未婚硕士研究生4医师医生
N20女51已婚本科31副主任护师护士
N21女32已婚专科11护师护士
N22女41已婚本科19主管护师护士
N23男46已婚硕士研究生21主任医师医生
N24男31已婚硕士研究生6医师医生
N25女31未婚专科10护师护士
N26男41已婚本科18主管护师护士
N27女37已婚博士研究生8主治医师医生
N28男33已婚硕士研究生7医师医生
), ArticleFig(id=1322936871080304851, tenantId=1146029695717560320, journalId=1220038315760373764, articleId=1322936856698036381, language=EN, label=Table 2, caption=

General information of family members of dying patients in ICU(n=12)

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编号性别年龄（岁）婚姻状况职业文化程度与病人的关系
F1男30已婚职员专科子女
F2女39已婚事业单位人员本科子女
F3女49已婚工人初中配偶
F4男58已婚农民小学配偶
F5男36已婚工人中专配偶
F6女33未婚事业单位人员硕士研究生子女
F7女34已婚个体户中专子女
F8女42离异个体户高中子女
F9男55已婚无业小学父母
F10女26未婚职员中专子女
F11男28已婚个体户本科子女
F12女44已婚职员本科子女
), ArticleFig(id=1322936871168385236, tenantId=1146029695717560320, journalId=1220038315760373764, articleId=1322936856698036381, language=CN, label=表2, caption=

重症监护室临终病人家属一般资料（n=12）

, figureFileSmall=null, figureFileBig=null, tableContent=
编号性别年龄（岁）婚姻状况职业文化程度与病人的关系
F1男30已婚职员专科子女
F2女39已婚事业单位人员本科子女
F3女49已婚工人初中配偶
F4男58已婚农民小学配偶
F5男36已婚工人中专配偶
F6女33未婚事业单位人员硕士研究生子女
F7女34已婚个体户中专子女
F8女42离异个体户高中子女
F9男55已婚无业小学父母
F10女26未婚职员中专子女
F11男28已婚个体户本科子女
F12女44已婚职员本科子女
), ArticleFig(id=1322936871445209301, tenantId=1146029695717560320, journalId=1220038315760373764, articleId=1322936856698036381, language=EN, label=Table 3, caption=

Results of the evaluation of factors influencing the implementation of shared decision-making in terminally ill patients in ICU

, figureFileSmall=null, figureFileBig=null, tableContent=
CFIR的构成要素分类结果
主题1：共同决策的特征共同决策的来源阻碍作用较弱
共同决策的相对优势促进作用较强
共同决策的复杂性促进作用较弱
共同决策的费用阻碍作用较强
主题2：外部因素领域当地看法阻碍作用较强
当地条件阻碍作用较弱
政策与法规阻碍作用较强
外部压力阻碍作用较强
主题3：内部因素领域结构特征阻碍作用较强
文化阻碍作用较弱
创新激励机制产生中性影响
可用资源阻碍作用较弱
知识和信息的获取阻碍作用较强
主题4：个体领域需求促进作用较强
能力阻碍作用较强
机会阻碍作用较弱
动力阻碍作用较弱
), ArticleFig(id=1322936871529095382, tenantId=1146029695717560320, journalId=1220038315760373764, articleId=1322936856698036381, language=CN, label=表3, caption=

重症监护室临终病人医患共同决策实施影响因素评级结果

, figureFileSmall=null, figureFileBig=null, tableContent=
CFIR的构成要素分类结果
主题1：共同决策的特征共同决策的来源阻碍作用较弱
共同决策的相对优势促进作用较强
共同决策的复杂性促进作用较弱
共同决策的费用阻碍作用较强
主题2：外部因素领域当地看法阻碍作用较强
当地条件阻碍作用较弱
政策与法规阻碍作用较强
外部压力阻碍作用较强
主题3：内部因素领域结构特征阻碍作用较强
文化阻碍作用较弱
创新激励机制产生中性影响
可用资源阻碍作用较弱
知识和信息的获取阻碍作用较强
主题4：个体领域需求促进作用较强
能力阻碍作用较强
机会阻碍作用较弱
动力阻碍作用较弱
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ICU临终病人医患共同决策影响因素的质性研究
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周微微 1 , 张黄鑫 1 , 刘梦婕 2, *, * , 刘兰 3 , 韦皓 3
护理研究 | 综合研究 2026,40(11): 1925-1933
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护理研究 |综合研究 2026 , 40 (11) : 1925 -1933
ICU临终病人医患共同决策影响因素的质性研究
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周微微1, 张黄鑫1, 刘梦婕2, *, * , 刘兰3, 韦皓3
作者信息
  • 1西南医科大学附属医院，四川 646000
  • 2成都中医药大学附属中西医结合医院（成都市第一人民医院）
  • 3西南医科大学
通讯作者:
刘梦婕，E-mail：
LIU Mengjie, E-mail:
作者简介:

周微微，硕士研究生

Qualitative study on the influencing factors of doctor-patient shared decision-making in ICU terminally ill patients
Weiwei ZHOU1, Huangxin ZHANG1, Mengjie LIU2 , Lan LIU3, Hao WEI3
Affiliations
  • 1Affiliated Hospital of Southwest Medical University, Sichuan 646000 China
  • 2Chengdu Integrated TCM & Western Medicine Hospital(Chengdu First People's Hospital)
  • 3Southwest Medical University
出版时间: 2026-06-10 doi: 10.12102/j.issn.1009-6493.2026.11.016
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摘要
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目的

基于实施性研究综合框架（CFIR）系统分析重症监护室（ICU）临终病人医患共同决策的影响因素，为构建本土化护理实践策略提供依据。

方法

采用目的抽样法，于2024年3月—6月选取四川省某三级甲等医院28名重症监护室医务人员、12名重症监护室临终病人家属进行半结构式访谈，运用定向内容分析法结合CFIR进行编码分析并评级。

结果

共映射出4个主题：共同决策的特征（共同决策的来源，共同决策的相对优势，共同决策的复杂性，共同决策的费用）、外部因素领域（当地看法，当地条件，政策与法规，外部压力）、内部因素领域（结构特征，文化，创新激励机制，可用资源，知识和信息获取）、个体领域（需求，能力，机会，动力）。评级确定了13个障碍因素、3个促进因素及1个中性因素。

结论

医患共同决策的实施受文化、政策、资源及能力等多维度的交互影响，亟须构建本土化共同决策实施策略、开发家属决策支持工具及联动改革医保、伦理法律政策，以提升临终决策质量。

共同决策  /  影响因素  /  重症监护室  /  临终病人  /  临终决策  /  安宁疗护  /  实施性研究综合框架
Objective

To systematically analyze the influencing factors of doctor-patient decision-making for terminally ill patients in the intensive care unit(ICU) based on the consolidated framework for implementation research(CFIR),so as to provide a basis for constructing localized nursing practice strategies.

Methods

Using purposive sampling method,a total of 28 medical staff in the intensive care unit and 12 family members of terminally ill patients from a tertiary grade A hospital in Sichuan province were selected for semi-structured interviews from March to June 2024.Directed content analysis combined with CFIR was used for coding analysis and rating.

Results

Four core themes are identified:the characteristics of shared decision-making sources of shared decision-making,relative advantages of shared decision-making,complexity of shared decision-making,costs of shared decision-making),external factor domains(local perspectives,local conditions,policies and regulations,external pressures),internal factor domains(structural features,culture,innovation incentive mechanisms,available resources,knowledge and information acquisition),and individual characteristics(needs,capabilities,opportunities,motivation).The rating identified 13 barrier factors,3 facilitating factors,and 1 neutral factor.

Conclusions

The implementation of shared decision-making is influenced by multiple dimensions,such as culture,policies,resources,and capabilities.It is urgent to establish localized shared decision-making implementation strategies,develop decision-support tools for family members,and jointly reform medical insurance,ethics,and legal policies to improve the quality of end-of-life decision-making.

shared decision-making  /  influencing factors  /  intensive care unit  /  terminally ill patients  /  end-of-life decision-making  /  palliative care  /  consolidated framework for implementation research, CFIR
周微微, 张黄鑫, 刘梦婕, 刘兰, 韦皓. ICU临终病人医患共同决策影响因素的质性研究. 护理研究, 2026 , 40 (11) : 1925 -1933 . DOI: 10.12102/j.issn.1009-6493.2026.11.016
Weiwei ZHOU, Huangxin ZHANG, Mengjie LIU, Lan LIU, Hao WEI. Qualitative study on the influencing factors of doctor-patient shared decision-making in ICU terminally ill patients[J]. Chinese Nursing Research, 2026 , 40 (11) : 1925 -1933 . DOI: 10.12102/j.issn.1009-6493.2026.11.016
正文
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截至2024年底，我国60岁及以上人口首次突破3亿人[1]，预计2050年，60岁以上人口比例达1/3，我国将成为超级老龄化社会[2]。人口老龄化加剧导致重症监护室（ICU）临终医疗需求激增，然而当前医疗体系过度依赖生命支持技术，无法逆转死亡结局，却显著增加了病人的身心痛苦，导致重症监护室的死亡质量评分总体偏低[3]。医患共同决策（shared decision-making，SDM）是一种新的医疗决策模式，强调医患双方基于循证医学证据、病人价值观及治疗目标共同制定医疗方案[4]。医患共同决策以病人为中心，对于无法自主决策的生命末期病人，家属需要通过细致、共情的方式探寻病人的潜在意愿。最佳实践指南推荐，采用医患共同决策可改善重症监护室病人临终决策[5-7]。研究显示，采用医患共同决策方式探讨临终治疗决策能够在不影响死亡率的前提下缩短重症监护室住院时间[8-10]，同时提升病人的临终质量和家属的临终决策满意度[10-12]，缓解家属的焦虑和痛苦[13]。但有许多影响因素阻碍医患共同决策在重症监护室临床实践的过程，涉及法律、伦理、医疗、文化等多种复杂因素。而现有医患共同决策实施影响因素研究中缺乏从个体、组织、团体、文化到外部环境的重症监护室临终场景特殊性的系统化考量。实施性研究综合框架（consolidated framework for implementation research，CFIR）是实施科学中应用最广泛的决定因素框架，由Damschroder等[14]于2009年开发，包含干预特征、个体特征、外部环境、内部环境和实施过程5个领域，共48个要素。这些要素相互作用影响干预方案的实施[15]，故CFIR可以指导辨析多层次的交互影响。因此，本研究采用半结构式访谈，以CFIR为基础分析，探究在重症监护室使用医患共同决策的多层级影响因素，为构建本土化实施策略提供依据。
1　对象与方法
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1.1　研究对象
2024年3月—6月，采用目的抽样法，以四川省某三级甲等综合医院的医务人员、重症监护室临终病人家属作为研究对象进行半结构式访谈。重症监护室医务人员纳入标准：1）重症监护室工作年限≥2年或从事重症监护室相关管理岗位工作≥5年的医生或护士；2）分管重症监护室病人；3）知情同意，愿意参与本研究。医务人员排除标准：1）脱离岗位≥3个月；2）实习或见习医务人员。重症监护室临终病人家属纳入标准：1）急性生理与慢性健康评估系统Ⅱ（APACHE Ⅱ）评分≥20分的重症监护室病人的家属；2）已完成至少1次病情沟通，病人入住重症监护室≥24 h；3）年龄≥18岁，为病人的主要决策人；4）自愿参与且能理解研究目的。排除存在未解决的医疗纠纷或严重心理障碍的家属。样本量以信息收集达到饱和为止，即在主题映射时，不再涉及新的主题，停止收集。最终纳入28名医务人员（编号N1~N28）及12名重症监护室临终病人家属（编号F1~F12），重症监护室医务人员一般资料见表1，重症监护室临终病人家属一般资料见表2。本研究已通过西南医科大学附属医院临床试验伦理委员会审批（受理号：KY2024175）。
1.2　研究方法
1.2.1　访谈提纲的确定
研究开始前，团队成员明确研究问题，查阅相关文献，参考CFIR官网[16]访谈问题清单设计访谈提纲。对3名医务人员、2名重症监护室临终病人家属进行预访谈，了解访谈中出现的问题，丰富访谈提纲，根据访谈对象的反馈及团队讨论形成访谈提纲终稿。
1.2.1.1　重症监护室医务人员访谈提纲
1）您赞同这种共同决策的模式吗？为什么？2）您认为共同决策模式复杂吗？为什么？3）您认为共同决策应该怎样修改才能更好地被临床采纳？4）您认为哪些因素会影响共同决策的实施？您能从不同层面阐述吗？5）您认为成功实施共同决策还需要哪些资源？6）如果实施共同决策，您在干预方案中负责的工作是什么呢？7）哪些因素会影响您为临终病人提供共同决策干预呢？8）您认为该方案对临终病人、家属和重症监护室有多重要？9）您对重症监护室实施医患共同决策有多大信心？为什么？
1.2.1.2　重症监护室临终病人家属访谈提纲
1）在今天了解概念之前，您知道共同决策是什么吗？2）您赞同这种共同决策模式吗？为什么？3）您认为共同决策模式复杂吗？为什么？4）您在决策中是否感受到了来自社会或文化的压力，比如放弃积极的治疗方式会受到亲戚、街坊的谴责？5）您认为在与医生沟通病人病情的过程中，有哪些资源不足，如沟通地点、时间、纸质材料等？6）医生或护士的沟通方式是否让您感到被尊重和理解？7）您希望以什么角色（主动、被动或共同）参与共同决策？为什么？8）您认为自己的医学知识或情绪状态是否影响了决策能力？为什么？
1.2.2　资料收集
采用半结构式访谈法收集资料，访谈地点为重症监护室会议室或单独办公室等不受干扰的私密空间。访谈过程中适时推进话题，保持中立，避免诱导性提示，营造轻松氛围。在访谈过程中观察受访者的神态、语气、动作及情绪变化并记录，访谈全程录音，每人访谈时间为30~40 min。访谈结束后24 h内将资料进行转录，将转录结果返给受访者以确保信息的准确性，撰写备忘录并反思访谈中存在的问题。
1.2.3　资料分析
根据访谈资料和新版CFIR的要素形成本研究的编码手册。研究者采用NVivo 14软件，使用定向内容分析法[17]，根据编码手册预设的主题对转录内容进行分析[18]。在进行主题映射时，反复地逐字逐句阅读，关注与理论相关的内容，并对其进行标记、提取相关语义与编码手册的定义对照，无法归纳的文本赋予新的编码。由2名研究者独立编码，有分歧时通过团队讨论解决。完成主题映射后对要素进行评级。评级由效价和强度构成，效价即对实施产生积极或消极影响的因素，根据CFIR提供的评级标准规定[18]，研究人员通过对质性文本分析识别促进因素（+）、障碍因素（-）、中性因素（0）。强度即事实产生的强影响（2）或弱影响（1），研究人员根据质性本文内容、录音及备忘录、受访者的一致程度、语言强度、具体例子判断影响强度。评级过程由2名研究人员独立完成，有分歧时通过团队讨论统一结果。
2　结果
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根据CFIR编码手册预设的主题，分别对重症监护室医务人员、病人家属访谈结果进行主题映射，最终映射出4个主题，包括共同决策的特征、外部因素领域、内部因素领域、个体领域。
2.1　主题1：共同决策的特征
共同决策的特征是指共同决策的实践、想法或干预本身的“可实施性”，映射要素包括共同决策的来源、相对优势、复杂性及花费。
2.1.1　共同决策的来源
共同决策干预模式的来源指受访者对共同决策干预可靠性的认知。大多数医务人员认为其源自“知情同意”，但对其构建过程、干预流程、内涵尚不清楚。N2：“没有听说过（共同决策）具体的概念，但是听说过一些类似的，比如说我们的知情同意嘛，知情同意就相当于这个共同决策的一个简化版”。N26：“只知道这个模式来自西方，已经在实行了，其他的不了解”。
2.1.2　共同决策的相对优势
相对优势指共同决策与当前沟通模式相比具有的优势。大部分受访者对共同决策持肯定态度，重症监护室医务人员认为共同决策比以往的决策方式更能够减少医疗纠纷，家属则认为采用共同决策更加尊重病人、家属意愿，让决策选项更加清晰。N8：“比我们之前那种沟通方式好，因为我们现在这种沟通方式就是单向的，家属或者病人对很多方面可能不是很了解”。F6：“这种方式（共同决策）更好点，让我们更加了解一些不同的治疗方法，我们的想法是什么，让我们想清楚，而不是单纯像医生说的治或不治”。
2.1.3　共同决策的复杂性
共同决策的复杂性指共同决策实施的复杂程度。大部分医务人员、病人家属认为共同决策的流程不复杂，但要保证实施质量需要足够的时间进行深入的讨论。N8：“其实整个实施过程不复杂，但是这种沟通的话要做到很细致化，因为如果你一旦没有达到家属预期想要的一些结果，就会产生一些矛盾。所以说还是要费很大的人力，还有时间去完成这些事情”。F12：“感觉不复杂的，关键就是要讲通，让我们完全理解到可能还是要花时间”。
2.1.4　共同决策的费用
共同决策的费用指共同决策实施过程中需要的必要支出。部分医务人员认为共同决策的费用主要来源于人力成本。N27：“我觉得这个（共同决策）实施的话，占用的人力资源还是比较多，因为会抽一部分人或一部分人的时间，坐着跟家属谈”。但是近年来医院人力资源管理承受较大的压力，可能阻碍共同决策的实施。N23：“因为现在医院在人力成本的问题上都在减人”。部分家属则表示不愿意承担共同决策的花费。F4：“你这个（共同决策）要出钱的话，可能还是不愿意的，能够报销当然最好了”。
2.2　主题2：外部因素领域
外部因素领域是外部环境和情景对共同决策实施产生的影响，此维度中映射当地看法、当地条件、政策与法规、外部压力4个要素。
2.2.1　当地看法
当地看法指当地的社会文化价值观对实施共同决策的影响。医务人员认为传统的孝道观念产生的压力导致家属无法通过共同决策的方式理性地考虑病人的意愿，从而决定是否继续维持生命支持治疗。N9：“其实这个病人没有什么治疗意义，已经给家属表达得很清楚，但是由于受到一些他自认为道德的束缚，觉得不能放弃，会被别人戳脊梁骨，特别是乡村邻里的评价”。此外，中国人重视家庭，认为尽孝的表现就是竭尽全力救治生命。F8：“有钱我肯定再怎么样我都要尽全力地治，自己的爸妈不给他治啊？这种事做不出来”。
2.2.2　当地条件
当地条件主要指当地经济条件对共同决策实施产生的影响。部分受访者认为当地经济条件与大城市差距较大加之年轻人口外流，导致病人、家属的知识、文化和对新事物的接受程度差异较大，难以配合共同决策的实施。N11：“我们西南片区和北上广深相比差距大，当然这个（共同决策）实施起来肯定还是要受当地经济条件的影响”。N17：“我们这地方是输出型的省份，我们出去打工的人比较多，所以说真正留下来能够决策的人，他的决策能力是受影响的”。F4：“我们那里农村条件不好，没读几天书，没见过世面，我要是懂得多，我也说得头头是道”。
2.2.3　政策与法规
政策与法规指当地法律、规章对实践、推广共同决策的影响。医务人员认为重症监护室共同决策不仅依赖临床实践的经验与专业知识，还深受政策法规的指导和约束。N4：“如果在政策上面去规范的话是最好的，这种病人是不是没有治疗前景，有哪些治疗方案，不要避讳全部拿出来探讨，医院层面才可能自上而下地重视这个事情”。在规定医疗团队面对临终病人时应遵循的程序和原则还不完善。N17：“从法律这个角度上来说，他具不具备能够帮病人这个时候做决策？比如有些工伤的病人，可能他的家人离他很远，这个时候来的是谁？法律上怎么界定他决策的资质？而且生前预嘱还不具备法律效力”。
2.2.4　外部压力
外部压力指能够驱动或阻碍共同决策实施的外部影响。部分医务人员认为目前医患关系处于比较紧张的状态，导致其尝试共同决策时存在顾虑。N14：“像现在很多老百姓，他们的一些对立思想，还有对医疗对立的状态，会（对共同决策）有影响”。但部分家属也表达了不同的观点，F11：“这个医院还是很好的，我们还是多相信医生的”。有受访者认为实行绩效改革以后也会影响共同决策的实施。N17：“绩效改革后影响很大，尤其是按操作项目付费，你的操作越多，操作越复杂越有难度，医保资金就会得到更多的回馈。如果按病种付费的话，有可能本来我该做的我又不做了，对不对？两者都会产生比较大的影响，主要是项目可不可以收费，影响长期执行”。
2.3　主题3：内部因素领域
内部因素领域指的是组织内部对实施共同决策产生的影响。在此维度中映射包括结构特征、文化、创新激励机制、可用资源、知识和信息获取5个要素。
2.3.1　结构特征
结构特征指开展共同决策所需的个人和团队内部之间的责任及人员配置情况。大多数医务人员表示目前重症监护室的工作量大且人力资源紧张，难以开展共同决策。N6：“因为我们现在的工作量太大了，你不能再给我们增加工作”。家属也表示由于医务人员工作繁忙，缺少沟通交流的机会。F7：“医生太忙了，没时间给我们说很多”。也有医务人员表示倒班原因会导致共同决策的推进缺乏连续性。N6：“每天的管床老师都在不停地变化，有可能导致今天上班的医务人员并不清楚病人的情况”。有医务人员认为团队内部要加强合作，团队内部达成共识才能促进共同决策。此外，护士参与到共同决策中能够提供关于病人更加全面的信息。N7：“医护信息的同质化很重要，不能同一个团队不同的人沟通的时候给患方表达意思不一样，这样的话病人肯定就不信任了”。F7：“有时候护士比医生更有耐心，在我们探视的时候还给我们讲讲病人情况”。
2.3.2　文化
文化指人员内部之间普遍认同的价值观。医务人员表示由于在高强度的工作环境中，会偏向于更有“目的性”的沟通方式。N3：“在大环境影响下，我在沟通的时候希望花费的时间能够尽量短，在最短的时间完成任务，目的性比较强”。部分医务人员认为其职责就是竭尽所能抢救生命，而不是考虑是否维持病人的生命支持治疗。N20：“医生一般情况下的选择就是积极治疗，有一线希望我们都要医，而没有过多考虑其他方式”。
2.3.3　创新激励机制
创新激励机制指有形或无形的激励或奖励以促进共同决策的实施。部分医务人员认为适当的激励措施能够促进共同决策的实施。N3：“比如说沟通的人，我参加了1例，我可能在绩效上面就会有所体现，那肯定积极性会更高啊，大家也会更愿意去干这个事情啊”。除绩效激励以外有的医务人员还表示应该给予职称晋升的便利，或者采用科研课题的方式激励共同决策的实施。N3：“比如说除了绩效其实在职称提升啊各方面吧，干这个事情对我有利”。N26：“比如有课题的激励，可能也会去干”。
2.3.4　可用资源
可用资源指具备实施和推广共同决策的场所和资源供应。医务人员认为共同决策应该是很慎重的，需要私密的空间和独立的环境。N17：“空间包括一个安静的环境，一种氛围，这种氛围就是包括你的光线色调，可以让病人家属放松”。病人家属表示目前缺乏相对安静的环境去完成病情沟通。F3：“医生很多时候就在过道上把一些情况说了，时间又紧，有时候真的太吵了”。除对场所资源要求以外，为保证共同决策的进展顺利，也有医务人员表示应该在决策前提供相关的资料、模型或者录像。N3：“比如说科室可以给他提供一些相对简单的资料、模型或者录像，在共同决策之前让他心里大概有个数”。
2.3.5　知识和信息的获取
知识和信息的获取指对共同决策干预的了解情况和相关培训的可获得性。许多医务人员表示并不了解有关共同决策的相关知识，由此导致对临终病人及家属的人文关怀不够。N9：“最主要的原因是观念没有全方位地开展，让医护人员有这个理念。我们重症监护室的医务人员其实在面临病人或者病人家属进来的那一刻，实际上很多时候是很无措的”。由于医务人员对共同决策的认识有限，家属则更难有机会接触共同决策的相关信息。F5：“我们哪里晓得这些哦，我们能做的就是尽量配合医生嘛”。因此，医务人员也表示应该要加强培训。N2：“肯定都需要培训，需要经过专门的培训，培训了之后你还要考核他们是不是已经达到这个要求了，要不然他表达不清楚”。
2.4　主题4：个体领域
在行为改变轮理论的COM-B模型[19]中能力、机会和动力三者相互影响能直接或间接影响个体行为，CFIR个体特征亚领域采用了COM-B模型3要素并新增需求的要素解释个体行为的变化，在此维度中映射需求、能力、机会和动力4个要素。
2.4.1　需求
需求指目前临终病人医患沟通不足，需要共同决策干预去解决的部分。大多数家属表示共同决策的方式更符合其需求，期望以共同决策的方式解决当前决策困境。F5：“像我们现在是半个小时的探视时间，很多时候是通过电话与医生沟通了几句，很多事情病人在里面啥情况都没有了解全面，可能我会更愿意采取这种方式（共同决策）”。F6：“我觉得我们应该通过共同决策讨论一下步应该怎么办，因为我也在想到底治不治，或者该怎么去治，看见病人痛苦我们也难受，但是又不想放弃”。
2.4.2　能力
能力指医患双方知识或技能等对共同决策干预实施的影响。受访者认为参与双方要具备较好的沟通能力，才能促使共同决策顺利推进，首先医务人员要具备较好的沟通能力。N13：“主要的还是沟通能力，医生护士的主动表达和被动表达”。其次大部分临终病人家属对医疗过程的不理解，导致与医务人员的沟通存在不同频的情况，直接影响其参与共同决策的质量。F1：“有时候医生和我沟通，我可能都不太能理解在表达什么，更不要说那种病情很复杂的，可能了解个大概”。
2.4.3　机会
机会指个体要完成共同决策所具备的基本条件。大部分受访者表示，在重症监护室的病人由于病情原因缺乏表达自我治疗意愿的机会，主要是由家属替代决策。N10：“其实对于重症监护室的病人来说，很多都是昏迷的，其没有自主意识，一般是家属参与”。因此，受访者认为参与共同决策的医务人员要具备丰富的经验，能为病人疾病提供专业的判断，提高病人的信任度。N7：“你对这个疾病的认知要非常清楚，而且要求绝对是有经验的医生跟他讲，让病人家属对你产生极强的信任感”。病人家属在医患关系中的被动角色，让他们缺乏真正加入决策的机会。F11：“我们也不太懂，我们信任医生，医生说怎么办，我们就怎么做”。
2.4.4　动力
动力指个体致力于完成共同决策的内在意愿。医务人员的性格因素会影响他们是否自愿实践共同决策模式。N17：“外向一点的医生愿意交流，因为有些医生简单两句话，病人不行了，请你准备怎么样，但是并没有进行更深入的沟通”。N10：“有些人他来上班，他就会觉得我每天完成我的工作就可以了，有些人会积极主动实施和参与这个方案，也有些人他会觉得我不感兴趣，没有参与的动力”。部分家属表示对家庭的责任心会影响他们是否关注病人的需求。F12：“像我们就是很有孝心的了，天天在这里守着，有些家属不愿意花更多的时间，病人本身也是昏迷的，就不关心”。
2.5　评级
评级后确定了13个障碍因素、3个促进因素及1个中性因素，详见表3。
3　讨论
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3.1　共同决策方案：可行性与本土化挑战
本研究结果显示，医务人员、病人家属普遍认可共同决策的核心理念（如减少医患纠纷、尊重病人、家属意愿），且认为其实施步骤不复杂，具有可调整性和相对优势。然而，共同决策的实施面临显著的认知与实践鸿沟。部分医务人员将其等同于“知情同意”的简化版。杨林宁等[20]研究也发现，医务人员对共同决策的行为过程存在误解。这种认知局限提示可以在试点结合实际医疗场景优化流程，并通过多学科培训强化医务人员对共同决策理论依据的掌握。共同决策的人力资源花费成为重要阻碍，资金对人力资源的限制导致信息简化。家属也表示，难以负担额外的共同决策费用，采取医疗报销的方式才更有可能加入决策中。双方在支出、收费方面存在较大矛盾，即共同决策资源花费需要资金支持，而采用收费的方式又会降低病人参与决策的积极性，在现行医疗付费体系下，采用无偿的方式提供共同决策难以可持续性应用且制约其规模化推广。因此，需要进行成本效益分析测算进行共同决策服务定价，并推动医保补偿，才能满足双方需求；保障服务的可持续性，又可以避免过度医疗。
3.2　外部环境：文化限制与政策缺位的双重制约
质性研究凸显了传统孝道观念对共同决策的深刻影响。传统孝道观念和对死亡的恐惧担忧导致竭尽全力抢救是我国许多家庭的首要选择[21-22]。家属因“避免舆论指责”或“尽孝”观念倾向于维持积极治疗，加重了病人的痛苦。需要通过多平台的公众教育重塑“孝道”内涵，提倡尊重病人、家属意愿，理性选择，而非在不了解病人病情和可选择的治疗方案前盲目救治。法律和相关政策在实施共同决策中扮演着至关重要的角色，美国从2012年起陆续在几个州颁布有关共同决策的相关法律[23]。2020年，英国发布了国家医疗服务体系长期计划，以解决实施共同决策人员不足的问题[24]。我国虽颁布了《中华人民共和国基本医疗卫生与健康促进法》[25]，规定了公民是健康的第一责任人，肯定了病人在医疗中的自主权，但对于共同决策的规范化使用指导力度不足，相关的政策、法规并不完善，缺乏对“决策代理人资质”和“生前预嘱效力”的明确规定，加剧了医务人员的决策风险。提示需通过法律保障与伦理支持增强共同决策的合法性，需要更为完善的法律和制度规范。经济与地域差异亦不容忽视。受访者指出，当地经济条件影响共同决策的接受度，而医保付费改革带来的外部压力可能扭曲决策动机，没有医保收费项目的支撑，仅依靠医务人员的推动也难以持续性发展。Hsu等[26]研究发现，通过共同决策的方式开展家庭咨询与较少的重症监护室日均医疗支出有关。此外，医患关系紧张、病人及家属对医务人员的“信任危机”等外部环境给实施共同决策带来了压力和挑战。
3.3　组织内部：资源整合与激励机制的关键作用
质性研究显示，重症监护室组织结构特征与可用资源不足是共同决策实施的重要障碍。重症监护室工作强度高、家属抱怨“医生太忙，沟通时间不足”以及倒班导致决策连续性中断，决策沟通碎片化，缺乏私密沟通空间等问题，说明共同决策的推进依赖系统性支持而非仅依靠个体资历。此外，较大的工作压力使医务人员与病人及家属的交流短暂且形式化。医院层面应制定共同决策标准化流程，配备独立谈话间，并通过信息化工具（如预录病情讲解视频等方式）提升效率。同时，医务人员提出将共同决策纳入绩效考评或职称晋升体系，鼓励医护主动为病人、家属提供共同决策。在大部分医务人员的观念中，全力以赴地抢救病人是一种值得赞赏的行为，从而忽略了其他同样合理的选择[27]。有家属认为护士比医生更有耐心，可能源于重症监护室护士作为医疗服务的主要提供者和治疗决策的主要执行者，更了解病人的一般状况。因此，多学科合作模式十分重要，采用多学科合作的方式，加强团队内部与团队间的联系，如通过身心医学科的加入，为压力较大的决策者做心理疏导，或通过医务部调节医患双方已存在的矛盾，减少沟通壁垒。此外，病人治疗既要遵循专科意见，也要符合重症监护室具体情况，共同决策需要在进行正式会议前统一多学科意见，以确保信息的同质化。医务人员也表示共同决策的沟通能力十分关键，医务人员若不了解或不接受共同决策会直接阻碍其临床实践[20]。除加强对共同决策标准化流程的培训外，还应该加强对沟通技巧的培训，如解释治疗方案的风险、获益及不确定性，用通俗的语言传递医疗信息等。医院应该为医务人员提供更多培训机会，通过组织支持、分层培训等方式提高医务人员对共同决策的认知，逐步构建医患共同决策的实施氛围。共同决策与现有沟通模式部分契合，可通过分阶段整合（如先行聚焦重症监护室临终决策场景）再逐步扩大应用范围。
3.4　个体驱动：能力建设与需求响应的平衡
通过访谈可知大部分病人家属有参与共同决策的需求，但事实证明这种需求仍被低估[28]，家属需求与医患能力落差的矛盾尤为突出。尽管家属期望通过共同决策全面了解病情，但其教育水平、经济负担常导致参与度不足。医务人员则面临沟通能力、共情耐心和经验要求的挑战。对此，通过需求评估，了解不同背景经历的决策者适合的沟通方式以及信息提供方式，对学历较低的群体多采用可视化工具。同时，通过沟通模拟培训提升医务人员的情景应对能力。值得注意的是，动力因素的个体差异（如外向型医生更积极）提示需尊重医务人员的行为偏好。可通过自愿参与试点、赋予团队自主权激发医患双方参与决策的内在动力，也可以通过选择组织中善于接受、推广新事物的员工作为榜样力量改善内部文化氛围，以克服共同决策可能在实施中引起的冷漠或抵制。
4　小结
收起
共同决策在重症监护室中的实施受多层面因素影响（共同决策的特征、个体特征、组织内部及外部环境），其中主要的障碍因素有共同决策的人力资源花费、当地传统观念、政策与法规不完善、外部压力、人力资源缺乏、知识和信息的获取不足、医患双方沟通能力不足等多维度交互影响。亟须构建本土化共同决策实施策略、开发家属决策支持工具及联动改革医保、伦理法律政策，以提升临终决策质量。

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2026年第40卷第11期
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doi: 10.12102/j.issn.1009-6493.2026.11.016
  • 接收时间：2025-07-28
  • 首发时间：2026-10-30
  • 出版时间：2026-06-10
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  • 收稿日期：2025-07-28
  • 修回日期：2026-03-08
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    1西南医科大学附属医院，四川 646000
    2成都中医药大学附属中西医结合医院（成都市第一人民医院）
    3西南医科大学

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刘梦婕，E-mail：
LIU Mengjie, E-mail:
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鹅膏菌科Amanitaceae 2 11 5.26 鹅膏菌属 Amanita 10 4.78
小菇科 Mycenaceae 2 12 5.74 丝盖伞属 Inocybe 5 2.39
多孔菌科 Polyporaceae 8 14 6.70 蜡蘑属 Laccaria 5 2.39
红菇科 Russulaceae 3 23 11.00 小皮伞属 Marasmius 6 2.87
小菇属 Mycena 11 5.26
光柄菇属 Pluteus 5 2.39
红菇属 Russula 17 8.13
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