Wang Pin-Yung, Lai Wei-Shu, Yang Yu-Chin
Student, Department of Nursing, College of Medicine, National Cheng Kung University, Taiwan, ROC.
PhD, RN, Assistant Professor, Department of Nursing, College of Medicine, National Cheng Kung University, Taiwan, ROC.
Hu Li Za Zhi. 2019 Aug;66(4):103-109. doi: 10.6224/JN.201908_66(4).13.
Elderly patients with end stage renal disease (ESRD) frequently suffer from frailty, multiple comorbidities, and complications that greatly increase the mortality rate for this population. The irreversibility and variability of ESRD directly affect quality of life, which highlights the importance of gaining an early understanding of the preferences and expectations of these patients with regard to end-of-life care. This article describes a nursing experience that used ethical analysis to help an elderly ESRD patient and the dilemma faced by his family as to whether to sustain or withdraw hemodialysis. This article examines the uncertain trajectories of this disease and how to use shared decision making with the patient and his/her family to make the best decisions. A comprehensive assessment was conducted to identify the major health-related problems, to elicit the dilemmas faced in making the decision to sustain or end hemodialysis, and to understand the pain and suffering of the patient. Symptom control and comfort were identified as the most important goals of the patient, followed by building trust and rapport with his family. An analysis of the pros and cons of treatment was conducted using the 4-box ethical analysis developed by Josen, Siegler, and Winslade. The shared decision-making process was applied to help the patient express his expectations for his end-of-life care. While the health professionals considered that pain and suffering may influence the patient's decision, the patient found his connection between himself and others, self-value, and meaning of life through family love and support. A needs-based, flexible approach was adopted that established a continuous-care plan that was designed to provide the best care for the patient under a variety of possible scenarios while involving the family, which created a family-centered decision-making process that improved the quality of life of the elderly ESRD patient.
晚期肾病（ESRD）老年患者常伴有身体虚弱、多种合并症及并发症，这大大增加了该人群的死亡率。ESRD的不可逆性和变异性直接影响生活质量，这凸显了尽早了解这些患者对临终关怀的偏好和期望的重要性。本文描述了一次护理经历，运用伦理分析帮助一名老年ESRD患者及其家人解决关于维持还是停止血液透析的两难困境。本文探讨了这种疾病的不确定病程，以及如何与患者及其家人共同决策以做出最佳决定。进行了全面评估，以确定主要的健康相关问题，找出在决定维持或停止血液透析时面临的困境，并了解患者的痛苦。症状控制和舒适度被确定为患者最重要的目标，其次是与家人建立信任和融洽关系。使用由约森、西格勒和温斯莱德提出的四象限伦理分析方法对治疗的利弊进行了分析。应用共同决策过程帮助患者表达其对临终关怀的期望。虽然医护人员认为疼痛和痛苦可能会影响患者的决定，但患者通过家人的爱和支持找到了自己与他人的联系、自我价值以及生命的意义。采用了基于需求的灵活方法，制定了持续护理计划，旨在在各种可能情况下为患者提供最佳护理，同时让家人参与其中，从而创建了以家庭为中心的决策过程，提高了老年ESRD患者的生活质量。
