West Virginia University Center for Health Ethics and Law, Morgantown, WV 26506-9022, USA.
Clin J Am Soc Nephrol. 2010 Dec;5(12):2380-3. doi: 10.2215/CJN.07170810. Epub 2010 Nov 4.
Over a decade ago, the Renal Physicians Association and the American Society of Nephrology published the clinical practice guideline, Shared Decision-Making in the Appropriate Initiation of and Withdrawal from Dialysis, to assist nephrologists, patients, and families in making decisions to initiate and withdraw dialysis. Since then, researchers have extensively studied dialysis decision-making, and there is a substantial body of new evidence with regard to 1) the poor prognosis of some elderly stage 4 and 5 chronic kidney disease patients, many of whom are likely to die before initiation of dialysis or for whom dialysis may not provide a survival advantage over medical management without dialysis; 2) the prevalence of cognitive impairment in dialysis patients and the need to periodically assess them for decision-making capacity; 3) the under-recognition and undertreatment of pain and other symptoms in dialysis patients; 4) the underutilization of hospice in dialysis patients; and 5) the distinctly different treatment goals of ESRD patients based on their overall condition and personal preferences. The Renal Physicians Association developed this second edition of the guideline to provide clinicians, patients, and families with 1) the most current evidence about the benefits and burdens of dialysis for patients with diverse conditions; 2) recommendations for quality in decision-making about treatment of patients with acute kidney injury, chronic kidney disease, and ESRD; and 3) practical strategies to help clinicians implement the guideline recommendations.
十多年前，肾脏医师协会和美国肾脏病学会发布了临床实践指南《开始和停止透析的适当决策：共同决策》，以帮助肾病学家、患者和家属做出开始和停止透析的决策。自那时以来，研究人员广泛研究了透析决策，并且有大量新证据涉及：1）一些高龄 4 期和 5 期慢性肾脏病患者预后较差，其中许多人可能在开始透析之前死亡，或者对于这些患者，透析可能并不比不透析的单纯药物治疗提供生存优势；2）透析患者认知障碍的普遍存在，以及需要定期评估他们的决策能力；3）透析患者的疼痛和其他症状的识别和治疗不足；4）透析患者对临终关怀的利用不足；5）基于患者整体状况和个人偏好，终末期肾脏疾病患者的治疗目标明显不同。肾脏医师协会制定了本指南的第二版，为临床医生、患者和家属提供：1）关于不同条件下透析对患者的益处和负担的最新证据；2）关于急性肾损伤、慢性肾脏病和终末期肾脏疾病患者治疗决策质量的建议；3）帮助临床医生实施指南建议的实用策略。
