Bansal Amar D, Schell Jane O
Section of Palliative Care and Medical Ethics, Renal-Electrolyte Division, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
Semin Dial. 2018 Mar;31(2):170-176. doi: 10.1111/sdi.12667. Epub 2018 Jan 3.
Most patients who rely on dialysis for treatment of end-stage renal disease (ESRD) never receive a kidney transplant. Therefore, it is important for nephrology providers to feel comfortable discussing the role of dialysis near the end of life (EOL). Advance care planning (ACP) is an ongoing process of learning patient values and goals in an effort to outline preferences for current and future care. This review presents a framework for how to incorporate ACP in the care of dialysis patients throughout the kidney disease course and at the EOL. Early ACP is useful for all dialysis patients and should ideally begin in the absence of clinical setbacks. Check-in conversations can be used to continue longitudinal discussions with patients and identify opportunities for symptom management and support. Lastly, triggered ACP is useful to clarify care preferences for patients with worsening clinical status. Practical tools include prognostication models to identify patients at risk for decline; ACP documents to operationalize patient care preferences; and communication guidance for engaging in these important conversations. Interdisciplinary teams with expertise from social work, palliative care, and hospice can be helpful at various stages and are discussed here.
大多数依靠透析治疗终末期肾病（ESRD）的患者从未接受过肾移植。因此，肾脏病医疗服务提供者能够自如地讨论临终（EOL）透析的作用非常重要。预先护理计划（ACP）是一个持续了解患者价值观和目标的过程，旨在明确当前及未来护理的偏好。本综述提出了一个框架，说明如何在整个肾病病程及临终阶段将ACP纳入透析患者的护理中。早期ACP对所有透析患者都有用，理想情况下应在没有临床挫折时开始。定期沟通对话可用于与患者持续进行纵向讨论，并确定症状管理和支持的机会。最后，触发式ACP有助于明确临床状况恶化患者的护理偏好。实用工具包括用于识别病情恶化风险患者的预后模型；将患者护理偏好付诸实施的ACP文件；以及进行这些重要对话的沟通指南。来自社会工作、姑息治疗和临终关怀领域的跨学科团队在各个阶段都可能有所帮助，本文将对此进行讨论。
