Department of Medicine, Duke University, Durham, NC; Center for Health Services Research in Primary Care, Durham VA Medical Center, Durham, NC 27705, USA.
Am J Kidney Dis. 2012 Apr;59(4):495-503. doi: 10.1053/j.ajkd.2011.11.023. Epub 2012 Jan 4.
Elderly patients with advanced kidney disease experience considerable disability, morbidity, and mortality. Little is known about the impact of physician-patient interactions on patient preparation for the illness trajectory. We sought to describe how nephrologists and older patients discuss and understand the prognosis and course of kidney disease leading to renal replacement therapy.
We conducted focus groups and interviews with 11 nephrologists and 29 patients older than 65 years with advanced chronic kidney disease or receiving hemodialysis. Interviews were audiorecorded and transcribed. We used qualitative analytic methods to identify common and recurrent themes related to the primary research question.
We identified 6 themes that describe how the kidney disease trajectory is discussed and understood: (1) patients are shocked by their diagnosis, (2) patients are uncertain how their disease will progress, (3) patients lack preparation for living with dialysis, (4) nephrologists struggle to explain illness complexity, (5) nephrologists manage a disease over which they have little control, and (6) nephrologists tend to avoid discussions of the future. Patients and nephrologists acknowledged that prognosis discussions are rare. Patients tended to cope with thoughts of the future through avoidance by focusing on their present clinical status. Nephrologists reported uncertainty and concern for evoking negative reactions as barriers to these conversations.
Patients and nephrologists face challenges in understanding and preparing for the kidney disease trajectory. Communication interventions that acknowledge the role of patient emotion and address uncertainty may improve how nephrologists discuss disease trajectory with patients and thereby enhance their understanding and preparation for the future.
患有晚期肾脏疾病的老年患者会经历相当大的残疾、发病率和死亡率。关于医患互动对患者为疾病轨迹做准备的影响知之甚少。我们试图描述肾病医生和老年患者如何讨论和理解导致肾脏替代治疗的肾脏疾病的预后和病程。
我们对 11 名肾病医生和 29 名年龄在 65 岁以上的患有晚期慢性肾脏疾病或接受血液透析的患者进行了焦点小组和访谈。访谈进行了录音和转录。我们使用定性分析方法确定与主要研究问题相关的常见和反复出现的主题。
我们确定了 6 个主题，描述了如何讨论和理解肾脏疾病轨迹：（1）患者对他们的诊断感到震惊，（2）患者不确定他们的疾病将如何进展，（3）患者缺乏接受透析治疗的准备，（4）肾病医生难以解释疾病的复杂性，（5）肾病医生管理他们几乎无法控制的疾病，（6）肾病医生倾向于避免讨论未来。患者和肾病医生都承认预后讨论很少。患者倾向于通过关注他们目前的临床状况来避免思考未来，从而应对未来的想法。肾病医生报告说，不确定性和对引起负面反应的担忧是这些对话的障碍。
患者和肾病医生在理解和为肾脏疾病轨迹做准备方面面临挑战。承认患者情绪作用并解决不确定性的沟通干预措施可能会改善肾病医生与患者讨论疾病轨迹的方式，从而增强他们对未来的理解和准备。
