Centre for Biomedical Ethics, National University of Singapore, Singapore.
Centre for Applied Ethics, University of British Columbia, Vancouver, British Columbia, Canada.
J Am Geriatr Soc. 2015 Aug;63(8):1674-8. doi: 10.1111/jgs.13531. Epub 2015 Jul 22.
In the age of person-centered care, there is an emphasis on promoting patient autonomy and surrogate decision maker authority in making treatment decisions that are aligned with the patient's priorities and values. As technological advances offer multiple clinical options with various levels and types of risks and benefits, person-centered clinical practice encourages the incorporation of patients' and families' heterogeneous experiences into decisions regarding illness management. In caring for frail elderly adults, clinicians are sometimes faced with situations in which individuals and their surrogate decision-makers request a treatment that the clinicians feel is clinically inappropriate. This article provides a case example of a frail older adult with advanced chronic kidney disease who requests dialysis despite the advice of his nephrologist to pursue conservative management. The four-box approach, which provides clinicians with a structured ethical framework to facilitate informed and ethically justified treatment decisions, is then introduced. By considering the patient's medical indications, preferences, quality of life, and contextual factors, how each consideration plays a unique yet equally important role in informing clinically responsible and person-centered care is illustrated.
在以患者为中心的护理时代，强调促进患者自主和代理人决策权威，以做出与患者优先事项和价值观一致的治疗决策。随着技术进步提供了多种具有不同程度和类型风险与收益的临床选择，以患者为中心的临床实践鼓励将患者和家属的异质性经验纳入疾病管理决策中。在照顾体弱的老年患者时，临床医生有时会面临这样的情况：患者及其代理人要求进行临床医生认为不适当的治疗。本文提供了一个体弱的老年晚期慢性肾脏病患者的案例，尽管他的肾病医生建议进行保守治疗，但他仍要求进行透析。然后引入了四框方法，为临床医生提供了一个结构化的伦理框架，以促进知情和伦理上合理的治疗决策。通过考虑患者的医疗指征、偏好、生活质量和背景因素，说明了每一个考虑因素如何在告知临床负责和以患者为中心的护理方面发挥独特而同样重要的作用。
