Department of Medicine, Division of Nephrology, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA,
Division of Palliative Care, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA,
Am J Nephrol. 2020;51(1):35-42. doi: 10.1159/000504692. Epub 2019 Nov 27.
Although many older patients with end-stage renal disease and limited prognoses prefer conservative management (CM), it is not widely offered in the United States. Moreover, there is a dearth of US-based literature reporting clinical experience with shared decision making regarding CM of advanced chronic kidney disease (CKD).
We describe the clinical experience of 13 patients who opted for CM at the University of Rochester Medical Center's CKD clinic during 2016-2017. Main outcomes include: (1) reason for choosing CM, (2) completion of advance directives, (3) location of death, and (4) utilization of hospice service. Patients' reasons for choosing CM were categorized into 4 broad categories based on a review of their electronic medical records. A retrospective chart review conducted by 2 reviewers determined the status of advance care planning, hospice referral, and place of death.
The mean age of these patients was 81.8 years (SD 7.3). Their reasons for choosing CM included: poor prognoses; a wish to maintain their quality of life; their desire for a dignified life closure; and the intention to protect family members from having to see them suffer, based on their own memory of having witnessed a relative on dialysis previously. A total of 8 patients died: all received hospice services, 6 died at home, one at a nursing home, and one at a hospital. Advance care planning was completed in 100% of the cases. Symptoms were managed in collaboration with primary care physicians.
Patients' decisions to choose CM were influenced by their values and previous experience with dialysis, in addition to comorbidities and limited prognoses. Promoting the choice of CM in the United States will require training of clinicians in primary palliative care competencies, including communication and decision-making skills, as well as basic symptom management proficiencies.
尽管许多患有终末期肾病且预后不佳的老年患者更喜欢采用保守治疗（CM），但这种治疗在美国并未广泛应用。此外，美国缺乏有关在先进的慢性肾脏病（CKD）的 CM 方面进行共同决策的临床经验的相关文献。
我们描述了在 2016-2017 年期间，罗切斯特大学医学中心的 CKD 诊所中选择 CM 的 13 名患者的临床经验。主要结局包括：（1）选择 CM 的原因，（2）完成预先指示，（3）死亡地点，以及（4）临终关怀服务的使用。根据电子病历回顾，将患者选择 CM 的原因分为 4 个广泛的类别。两名审阅者进行的回顾性图表审查确定了预先护理计划、临终关怀转诊和死亡地点的状况。
这些患者的平均年龄为 81.8 岁（SD 7.3）。他们选择 CM 的原因包括：预后不佳；希望维持生活质量；希望尊严地结束生命；以及希望保护家庭成员免受看到他们受苦的痛苦，这是基于他们自己之前目睹过透析患者的记忆。共有 8 名患者死亡：所有患者均接受了临终关怀服务，6 名患者在家中死亡，1 名在疗养院，1 名在医院。100%的患者完成了预先护理计划。症状与初级保健医生合作进行管理。
患者选择 CM 的决定受到他们的价值观和之前对透析的经验的影响，以及共病和预后不佳的影响。在美国推广 CM 的选择将需要培训临床医生在初级姑息治疗方面的能力，包括沟通和决策技能，以及基本的症状管理能力。
