Lupu Dale, Moss Alvin H
Center for Aging, Health and Humanities, George Washington University, Washington, DC.
Center for Health Ethics and Law, West Virginia University School of Medicine, Morgantown, WV.
Semin Nephrol. 2021 Nov;41(6):580-591. doi: 10.1016/j.semnephrol.2021.10.010.
People living with kidney failure often experience a higher symptom burden (including anxiety and depression) and lower quality of life than patients with other serious chronic diseases. The end of life for these patients is characterized by high intensity of treatment (such as intensive care unit stays) and lack of support for family. Kidney supportive care, which emphasizes quality of life, person-centered care, and holistic care for the person and their family, is an approach that improves well-being by aligning care with the patient's preferences and goals. Kidney supportive care encompasses identifying seriously ill patients, eliciting patient values and goals through shared decision making and advance care planning, assessing and managing symptoms, communicating prognosis, offering active medical management without dialysis, and planning and managing care transitions, especially at the end of life. Models, strategies, and tools for incorporating kidney supportive care and active medical management without dialysis into existing workflows are available. However, barriers to implementation in the United States include clinician knowledge gaps, current workflows, and financial incentives, which make it difficult to break from the de facto default practice of starting dialysis for patients with kidney failure regardless of age, frailty, or debilitating condition. Policy changes are needed to fully implement kidney supportive care in the United States.
与其他严重慢性病患者相比，肾衰竭患者往往承受着更高的症状负担（包括焦虑和抑郁），生活质量也更低。这些患者的临终阶段表现为高强度治疗（如入住重症监护病房）且缺乏对家庭的支持。肾脏支持性护理强调生活质量、以人为本的护理以及对患者及其家庭的整体护理，是一种通过使护理与患者的偏好和目标相一致来改善幸福感的方法。肾脏支持性护理包括识别重症患者、通过共同决策和预先护理计划引出患者的价值观和目标、评估和管理症状、传达预后、在不进行透析的情况下提供积极的医疗管理，以及规划和管理护理过渡，尤其是在临终阶段。将肾脏支持性护理和不进行透析的积极医疗管理纳入现有工作流程的模式、策略和工具已经存在。然而，在美国实施过程中的障碍包括临床医生的知识差距、当前的工作流程和经济激励措施，这使得难以打破不顾患者年龄、虚弱程度或衰弱状况而对肾衰竭患者默认开始透析的实际做法。在美国全面实施肾脏支持性护理需要政策变革。
