与晚期肾病老年患者沟通治疗方案：一项会话分析研究。

Communicating treatment options to older patients with advanced kidney disease: a conversation analysis study.

机构信息

Palliative and End of Life Care Research Group, Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK.

Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK.

出版信息

BMC Nephrol. 2024 Nov 21;25(1):417. doi: 10.1186/s12882-024-03855-w.

DOI:10.1186/s12882-024-03855-w

PMID:39574029

原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC11580699/

Abstract

BACKGROUND

Choosing to have dialysis or conservative kidney management is often challenging for older people with advanced kidney disease. While we know that clinical communication has a major impact on patients' treatment decision-making, little is known about how this occurs in practice. The OSCAR study (Optimising Staff-Patient Communication in Advanced Renal disease) aimed to identify how clinicians present kidney failure treatment options in consultations with older patients and the implications of this for patient engagement.

METHODS

An observational, multi-method study design was adopted. Outpatient consultations at four UK renal units were video-recorded, and patients completed a post-consultation measure of shared decision-making (SDM-Q-9). Units were sampled according to variable rates of conservative management. Eligible patients were ≥ 65 years old with an eGFR of ≤ 20 mls/min/1.73m within the last 6 months. Video-recordings were screened to identify instances where clinicians presented both dialysis and conservative management. These instances were transcribed in fine-grained detail and recurrent practices identified using conversation-analytic methods, an empirical, observational approach to studying language and social interaction.

RESULTS

110 outpatient consultations were recorded (105 video, 5 audio only), involving 38 clinicians (doctors and nurses) and 94 patients: mean age 77 (65-97); 61 males/33 females; mean eGFR 15 (range 4-23). There were 21 instances where clinicians presented both dialysis and conservative management. Two main practices were identified: (1) Conservative management and dialysis both presented as the main treatment options; (2) Conservative management presented as a subordinate option to dialysis. The first practice was less commonly used (6 vs. 15 cases), but associated with more opportunities in the conversation for patients to ask questions and share their perspective, through which they tended to evaluate conservative management as an option that was potentially personally relevant. This practice was also associated with significantly higher post-consultation ratings of shared decision-making among patients (SDM-Q-9 median total score 24 vs. 37, p = 0.041).

CONCLUSIONS

Presenting conservative management and dialysis as on an equal footing enables patient to take a more active role in decision-making. Findings should inform clinical communication skills training and education.

CLINICAL TRIAL NUMBER

No trial number as this is not a clinical trial.

摘要

背景

对于患有晚期肾病的老年人来说，选择透析或保守的肾脏管理常常是一项具有挑战性的决策。虽然我们知道临床沟通对患者的治疗决策有重大影响，但对于这种影响是如何在实践中产生的，我们知之甚少。OSCAR 研究（优化晚期肾脏疾病中的医患沟通）旨在确定临床医生如何在与老年患者的咨询中提出肾脏衰竭的治疗方案，以及这对患者参与治疗的影响。

方法

采用观察性、多方法研究设计。在英国四家肾脏科的门诊进行视频记录，并在咨询后让患者完成一项共享决策测量（SDM-Q-9）。根据保守管理的不同比例对单位进行抽样。符合条件的患者年龄在 65 岁以上，过去 6 个月内 eGFR 为 ≤ 20ml/min/1.73m。筛选视频记录以确定临床医生提出透析和保守管理的情况。这些情况以细粒度的细节转录，并使用会话分析方法（一种研究语言和社会互动的经验性、观察性方法）识别反复出现的实践。

结果

记录了 110 次门诊咨询（105 次视频，5 次音频），涉及 38 名临床医生（医生和护士）和 94 名患者：平均年龄 77 岁（65-97 岁）；61 名男性/33 名女性；平均 eGFR 为 15（范围 4-23）。有 21 次临床医生提出了透析和保守管理。确定了两种主要做法：（1）保守管理和透析均被视为主要治疗方案；（2）保守管理被视为透析的下属选择。第一种做法使用较少（6 例与 15 例），但在对话中为患者提供了更多提问和分享观点的机会，通过这些机会，他们倾向于将保守管理评估为可能与个人相关的选择。这种做法也与患者咨询后共享决策的评分显著更高相关（SDM-Q-9 总分中位数 24 与 37，p=0.041）。