Bansal Amar D, O'Connor Nina R, Casarett David J
Renal-Electrolyte Division, Section of Palliative Care and Medical Ethics, University of Pittsburgh School of Medicine, 200 Lothrop St, Suite C1100, Pittsburgh, PA, 15213, USA.
Department of Medicine at the University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
BMC Nephrol. 2018 Aug 8;19(1):197. doi: 10.1186/s12882-018-0987-1.
Dialysis is often initiated in the hospital during episodes of acute kidney injury and critical illness. Little is known about how patients or their surrogate decision makers feel about dialysis initiation in the inpatient setting.
We conducted a prospective cohort study at a large academic center in the United States. All patients who initiated dialysis during a 30-day period in 2016 were approached for enrollment. Study participants were defined as individuals who provided consent for dialysis initiation - either the patient or a surrogate decision-maker. Decisional satisfaction and the degree of shared decision-making were assessed using the decisional attitude scale and the control preferences scale, respectively. These scales were incorporated into a study questionnaire along with an exploratory structured interview.
A total of 31 potential participants were eligible and 21 agreed to participate in the study. Continuous renal replacement therapy was used in 14 out of 21 cases (67%) and there was 33% in-hospital mortality in the study cohort. A majority (62%) of patients were unable to participate in the consent process for dialysis initiation and had to rely on a surrogate decision-maker. The mean score for the decisional attitude scale was 4.1 (95% CI 3.8-4.3) with a score of 5 corresponding to high decisional satisfaction. Most of the decisions were classified as shared and incorporated input from clinicians as well as patients or surrogates. Although 90% of participants agreed that they had a choice in making the decision, 81% were unable to mention any alternatives to dialysis initiation.
Dialysis initiation was associated with high decisional satisfaction and most participants felt that the decision incorporated input from patients and providers. However, inpatient dialysis initiation was commonly associated with loss of decisional capacity and reliance on a surrogate decision-maker. This finding is likely driven by critical illness. Survivors of critical illness who remain dialysis dependent may need to revisit conversations about the rationale, risks, and benefits of dialysis.
急性肾损伤和危重症发作期间，透析通常在医院开始。对于患者或其替代决策者对住院环境中开始透析的感受知之甚少。
我们在美国一家大型学术中心进行了一项前瞻性队列研究。2016年30天内开始透析的所有患者均被邀请入组。研究参与者被定义为同意开始透析的个体——患者或替代决策者。分别使用决策态度量表和控制偏好量表评估决策满意度和共同决策程度。这些量表与探索性结构化访谈一起纳入研究问卷。
共有31名潜在参与者符合条件，21名同意参与研究。21例中有14例（67%）使用了连续性肾脏替代治疗，研究队列的院内死亡率为33%。大多数（62%）患者无法参与开始透析的同意过程，不得不依赖替代决策者。决策态度量表的平均得分为4.1（95%可信区间3.8 - 4.3），得分5表示决策满意度高。大多数决策被归类为共同决策，并纳入了临床医生以及患者或替代者的意见。尽管90%的参与者同意他们在做决定时有选择，但81%的人无法提及开始透析的任何替代方案。
开始透析与较高的决策满意度相关，大多数参与者认为该决策纳入了患者和提供者的意见。然而，住院期间开始透析通常与决策能力丧失和依赖替代决策者有关。这一发现可能是由危重症导致的。仍依赖透析的危重症幸存者可能需要重新讨论透析的基本原理、风险和益处。
