Piccoli Giorgina Barbara, Sofronie Andreea Corina, Coindre Jean-Philippe
Department of Clinical and Biological Sciences, University of Torino, Torino, Italy.
Nephrology, Centre Hospitalier Le Mans, Avenue Roubillard, 72000, Le Mans, France.
BMC Med Ethics. 2017 Nov 9;18(1):61. doi: 10.1186/s12910-017-0219-4.
Starting dialysis at an advanced age is a clinical challenge and an ethical dilemma. The advantages of starting dialysis at "extreme" ages are questionable as high dialysis-related morbidity induces a reflection on the cost- benefit ratio of this demanding and expensive treatment in a person that has a short life expectancy. Where clinical advantages are doubtful, ethical analysis can help us reach decisions and find adapted solutions.
Mr. H is a ninety-year-old patient with end-stage kidney disease that is no longer manageable with conservative care, in spite of optimal nutritional management, good blood pressure control and strict clinical and metabolic evaluations; dialysis is the next step, but its morbidity is challenging. The case is analysed according to principlism (beneficence, non-maleficence, justice and respect for autonomy). In the setting of care, dialysis is available without restriction; therefore the principle of justice only partially applied, in the absence of restraints on health-care expenditure. The final decision on whether or not to start dialysis rested with Mr. H (respect for autonomy). However, his choice depended on the balance between beneficence and non-maleficence. The advantages of dialysis in restoring metabolic equilibrium were clear, and the expected negative effects of dialysis were therefore decisive. Mr. H has a contraindication to peritoneal dialysis (severe arthritis impairing self-performance) and felt performing it with nursing help would be intrusive. Post dialysis fatigue, poor tolerance, hypotension and intrusiveness in daily life of haemodialysis patients are closely linked to the classic thrice-weekly, four-hour schedule. A personalized incremental dialysis approach, starting with one session per week, adapting the timing to the patient's daily life, can limit side effects and "dialysis shock".
An individualized approach to complex decisions such as dialysis start can alter the delicate benefit/side-effect balance, ultimately affecting the patient's choice, and points to a narrative, tailor-made approach as an alternative to therapeutic nihilism, in very old and fragile patients.
高龄开始透析是一项临床挑战，也是一个伦理困境。在“极高”年龄开始透析的益处值得怀疑，因为与透析相关的高发病率促使人们反思这种要求高且昂贵的治疗对于预期寿命较短的人而言的成本效益比。当临床益处存疑时，伦理分析有助于我们做出决策并找到合适的解决方案。
H先生是一名90岁的终末期肾病患者，尽管进行了最佳营养管理、良好的血压控制以及严格的临床和代谢评估，保守治疗已无法控制病情；下一步是透析，但透析的发病率颇具挑战性。根据原则主义（行善、不伤害、公正和尊重自主权）对该病例进行了分析。在医疗环境中，透析不受限制；因此，在没有医疗保健支出限制的情况下，公正原则仅部分适用。是否开始透析的最终决定权在H先生（尊重自主权）。然而，他的选择取决于行善与不伤害之间的平衡。透析在恢复代谢平衡方面的益处是明确的，因此透析预期的负面影响起了决定性作用。H先生有腹膜透析的禁忌证（严重关节炎影响自我操作），并且觉得在护理帮助下进行腹膜透析会侵犯隐私。透析后疲劳、耐受性差、低血压以及血液透析患者日常生活受到干扰与经典的每周三次、每次四小时的治疗方案密切相关。一种个性化的递增透析方法，从每周一次开始，根据患者的日常生活调整时间安排，可以限制副作用和“透析休克”。
对于诸如开始透析这样的复杂决策采取个体化方法，可以改变微妙的益处/副作用平衡，最终影响患者的选择，并表明对于非常年老和脆弱的患者，一种叙述性的、量身定制的方法可作为治疗虚无主义的替代方案。
