Department of Occupational Therapy, Tufts University, Medford, Massachusetts.
Research on Aging, Ethics, and Community Health, Tufts University, Medford, Massachusetts.
Gerontologist. 2018 Mar 19;58(2):290-299. doi: 10.1093/geront/gnw267.
Between 2000 and 2012, the incident dialysis population in the United States increased by nearly 60%, most sharply among adults 75 years and older. End-of-life (EOL) conversations among dialysis patients are associated with better patient-centered outcomes and lower use of aggressive interventions in the last month of life. This study examined how health literacy may affect engagement, comprehension, and satisfaction with EOL conversations among elderly dialysis patients.
Qualitative/descriptive study with semi-structured interviews about health literacy, EOL conversations, and goals of care with 31 elderly dialysis patients at 2 centers in Boston. Themes were interpreted in the context of Nutbeam's health literacy framework.
Despite high mortality risk in this population, only 13% of patients had discussed EOL preferences with physicians, half had discussed EOL with their social network, and 25% of participants explicitly stated that they had never considered EOL preferences. Less than 30% of participants could correctly define terminology commonly used in EOL conversations. Analyses yielded 5 themes: (1) Misunderstanding EOL terminology; (2) Nephrologists reluctant to discuss EOL; (3) Patients conforming to socially constructed roles; (4) Discordant expectations and dialysis experiences; and (5) Reconciling EOL values and future care. Patients had limited understanding of EOL terminology, lacked of opportunities for meaningful EOL discussion with providers and family, resulting in uncertainty about future care.
Limited health literacy presents a substantial barrier to communication and could lead to older adults committing to an intensive pattern of care without adequate information. Clinicians should consider health literacy when discussing dialysis initiation.
在 2000 年至 2012 年间，美国接受透析治疗的患者人数增加了近 60%，其中 75 岁及以上的成年人增幅最为明显。终末期（EOL）患者与透析治疗相关的对话与更好的以患者为中心的结局和在生命的最后一个月降低使用激进干预有关。本研究探讨了健康素养如何影响老年透析患者参与、理解和对 EOL 对话的满意度。
对波士顿的 2 个中心的 31 名老年透析患者进行了关于健康素养、EOL 对话和护理目标的定性/描述性研究，采用半结构化访谈。主题是在 Nutbeam 的健康素养框架背景下进行解释的。
尽管该人群的死亡率很高，但只有 13%的患者与医生讨论过 EOL 偏好，一半的患者与他们的社交网络讨论过 EOL，25%的参与者明确表示他们从未考虑过 EOL 偏好。只有不到 30%的参与者能够正确定义 EOL 对话中常用的术语。分析得出了 5 个主题：（1）对 EOL 术语的误解；（2）肾病医生不愿意讨论 EOL；（3）患者顺应社会建构的角色；（4）期望和透析经历的不和谐；（5）调和 EOL 价值观和未来护理。患者对 EOL 术语的理解有限，缺乏与提供者和家人进行有意义的 EOL 讨论的机会，导致对未来护理的不确定性。
有限的健康素养是沟通的一个重大障碍，可能导致老年人在没有足够信息的情况下承诺接受强化的护理模式。临床医生在讨论开始透析治疗时应考虑健康素养。
