肾脏病学提供者对晚期肾病老年患者的预后感知和提供的护理。
Nephrology Provider Prognostic Perceptions and Care Delivered to Older Adults with Advanced Kidney Disease.
机构信息
Divisions of Nephrology and Hypertension.
Vanderbilt Center for Kidney Disease, Division of Nephrology and Hypertension, Nashville, Tennessee.
出版信息
Clin J Am Soc Nephrol. 2017 Nov 7;12(11):1762-1770. doi: 10.2215/CJN.03830417. Epub 2017 Sep 18.
BACKGROUND AND OBJECTIVES
Prognostic uncertainty is one barrier that impedes providers in engaging patients with CKD in shared decision making and advance care planning. The surprise question has been shown to identify patients at increased risk of dying.
DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: In our prospective observational study, 488 patients ≥60 years of age with CKD stage 4 or 5 were enrolled. Binary surprise question (, "Would you be surprised if this patient died in the next 12 months?") responses were recorded, and dialysis planning preferences, presence of advance care planning documentation, and care preceding death were abstracted.
RESULTS
The median patient age was 71 (65-77) years old. Providers responded no and yes to the surprise question for 171 (35%) and 317 (65%) patients, respectively. Median follow-up was 1.9 (1.5-2.1) years, during which 18% of patients died (33% of surprise question no, 10% of surprise question yes; <0.001). In patients with a known RRT preference (58%), 13% of surprise question no participants had a preference for conservative management (versus 2% of yes counterparts; <0.001). A medical order (, physician order for life-sustaining treatment) was documented in 13% of surprise question no patients versus 5% of yes patients (=0.004). Among surprise question no decedents, 41% died at home or hospice, 38% used hospice services, and 54% were hospitalized in the month before death. In surprise question yes decedents, 39% died at home or hospice (=0.90 versus no), 26% used hospice services (=0.50 versus no), and 67% were hospitalized in the month before death (=0.40 versus surprise question no).
CONCLUSIONS
Nephrologists' prognostic perceptions were associated with modest changes in care, highlighting a critical gap in conservative management discussions, advance care planning, and end of life care among older adults with CKD stages 4 and 5 and high-risk clinical characteristics.
PODCAST
This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2017_09_18_CJASNPodcast_17_11.mp3.
背景和目的
预后不确定性是阻碍提供者与 CKD 患者共同做出决策和进行预先护理计划的一个障碍。“惊讶问题”已被证明可识别出死亡风险增加的患者。
设计、设置、参与者和测量：在我们的前瞻性观察研究中，纳入了 488 名年龄≥60 岁、CKD 第 4 或 5 期的患者。记录了二项式惊讶问题（“如果这个患者在接下来的 12 个月内去世，你会感到惊讶吗？”）的回答，并提取了透析计划偏好、预先护理计划文件的存在以及死亡前的护理情况。
结果
中位患者年龄为 71（65-77）岁。提供者对惊讶问题的回答分别为否和是，分别为 171（35%）和 317（65%）名患者。中位随访时间为 1.9（1.5-2.1）年，在此期间，18%的患者死亡（惊讶问题否为 33%，惊讶问题是为 10%；<0.001）。在有已知 RRT 偏好的患者中（58%），惊讶问题否参与者中 13%有保守治疗的偏好（而惊讶问题是参与者中为 2%；<0.001）。13%的惊讶问题否患者有医疗医嘱（即医生对维持生命治疗的医嘱），而 5%的惊讶问题是患者有医嘱（=0.004）。在惊讶问题否死亡患者中，41%在家或临终关怀机构死亡，38%使用临终关怀服务，54%在死亡前一个月住院。在惊讶问题是死亡患者中，39%在家或临终关怀机构死亡（=0.90 与否），26%使用临终关怀服务（=0.50 与否），67%在死亡前一个月住院（=0.40 与惊讶问题否）。
结论
肾科医生的预后感知与护理的适度变化相关，突出了在 CKD 第 4 和 5 期和高危临床特征的老年患者中，保守治疗讨论、预先护理计划和临终关怀方面存在重大差距。
播客
本文包含一个播客，可在 https://www.asn-online.org/media/podcast/CJASN/2017_09_18_CJASNPodcast_17_11.mp3 上收听。
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