Schell Jane O, Cohen Robert A
Section of Palliative Care and Medical Ethics and Renal-Electrolyte Division, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; and
Department of Medicine, Nephrology Division, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts.
Clin J Am Soc Nephrol. 2014 Nov 7;9(11):2014-21. doi: 10.2215/CJN.02190314. Epub 2014 Jun 26.
Frail elderly patients with advanced kidney disease experience many of the burdens associated with dialysis. Although these patients constitute the fastest-growing population starting dialysis, they often suffer loss of functional status, impaired quality of life, and increased mortality after dialysis initiation. Nephrology clinicians face the challenges of helping patients decide if the potential benefits of dialysis outweigh the risks and preparing such patients for future setbacks. A communication framework for dialysis decision-making that aligns treatment choices with patient goals and values is presented. The role of uncertainty is highlighted, and the concept of a goal-directed care plan is introduced. This plan incorporates a time-limited trial that promotes frequent opportunities for reassessment. Using the communication skills presented, the clinician can prepare and guide patients for the dialysis trajectory as it unfolds.
患有晚期肾病的体弱老年患者承受着许多与透析相关的负担。尽管这些患者是开始透析的人群中增长最快的，但他们在开始透析后常常会出现功能状态丧失、生活质量受损以及死亡率增加的情况。肾脏病临床医生面临着帮助患者决定透析的潜在益处是否超过风险，以及让这些患者为未来的挫折做好准备的挑战。本文提出了一个透析决策的沟通框架，使治疗选择与患者的目标和价值观相一致。强调了不确定性的作用，并引入了目标导向护理计划的概念。该计划纳入了一个限时试验，以促进频繁的重新评估机会。运用所介绍的沟通技巧，临床医生可以在透析过程展开时为患者做好准备并给予指导。
