Division of Nephrology and Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York.
Divisions of Nephrology and Hypertension.
J Am Soc Nephrol. 2018 Dec;29(12):2870-2878. doi: 10.1681/ASN.2018060657. Epub 2018 Nov 1.
Older adults with advanced CKD have significant pain, other symptoms, and disability. To help ensure that care is consistent with patients' values, nephrology providers should understand their patients' priorities when they make clinical recommendations.
Patients aged ≥60 years with advanced (stage 4 or 5) non-dialysis-dependent CKD receiving care at a CKD clinic completed a validated health outcome prioritization tool to ascertain their health outcome priorities. For each patient, the nephrology provider completed the same health outcome prioritization tool. Patients also answered questions to self-rate their health and completed an end-of-life scenarios instrument. We examined the associations between priorities and self-reported health status and between priorities and acceptance of common end-of-life scenarios, and also measured concordance between patients' priorities and providers' perceptions of priorities.
Among 271 patients (median age 71 years), the top health outcome priority was maintaining independence (49%), followed by staying alive (35%), reducing pain (9%), and reducing other symptoms (6%). Nearly half of patients ranked staying alive as their third or fourth priority. There was no relationship between patients' self-rated health status and top priority, but acceptance of some end-of-life scenarios differed significantly between groups with different top priorities. Providers' perceptions about patients' top health outcome priorities were correct only 35% of the time. Patient-provider concordance for any individual health outcome ranking was similarly poor.
Nearly half of older adults with advanced CKD ranked maintaining independence as their top heath outcome priority. Almost as many ranked being alive as their last or second-to-last priority. Nephrology providers demonstrated limited knowledge of their patients' priorities.
患有晚期 CKD 的老年患者有严重的疼痛、其他症状和残疾。为了确保医疗照护符合患者的价值观，肾脏科医生在提出临床建议时，应了解患者的优先事项。
在 CKD 诊所接受治疗的年龄≥60 岁、患有晚期（4 或 5 期）非透析依赖性 CKD 的患者，使用经过验证的健康结果优先排序工具来确定其健康结果的优先事项。对于每位患者，肾脏科医生都完成了相同的健康结果优先排序工具。患者还回答了问题以自我评估其健康状况，并完成了临终情景工具。我们研究了优先事项与自我报告的健康状况之间的关联，以及优先事项与接受常见临终情景之间的关联，并衡量了患者的优先事项与医生对优先事项的看法之间的一致性。
在 271 名患者（中位年龄 71 岁）中，首要健康结果优先事项是保持独立性（49%），其次是活着（35%）、减轻疼痛（9%）和减轻其他症状（6%）。近一半的患者将活着排在第三或第四位。患者的自我报告健康状况与首要优先事项之间没有关系，但对某些临终情景的接受程度在不同首要优先事项的组之间有显著差异。医生对患者首要健康结果优先事项的看法只有 35%的时间是正确的。患者与医生在任何一个健康结果的排名上的一致性也很差。
近一半的患有晚期 CKD 的老年患者将保持独立性列为首要健康结果优先事项。几乎同样多的人将活着作为他们的最后或倒数第二的优先事项。肾脏科医生对患者的优先事项了解有限。
