Discussing Conservative Management With Older Patients With CKD: An Interview Study of Nephrologists.
Discussing Conservative Management With Older Patients With CKD: An Interview Study of Nephrologists.
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DOI：
10.1053/j.ajkd.2017.11.011
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发表时间：
2018-05
期刊：
影响因子：
--
通讯作者：
Wong JB
中科院分区：
文献类型：
--
作者：
Ladin K;Pandya R;Kannam A;Loke R;Oskoui T;Perrone RD;Meyer KB;Weiner DE;Wong JB
尽管透析可能不会为老年肾衰竭患者提供很大的生存益处，但很少有人了解保守治疗（CM）。讨论CM的障碍和促进因素以及肾脏病学家提出CM选项的决定可能在肾脏病提供者社区内有所不同。肾脏病学家的访谈研究根据性别、执业年限、执业类型和地区对美国肾脏病学家的国家样本进行抽样。定性半结构化访谈持续到主题饱和。对录音和转录访谈的主题和叙述分析。在35个半结构化的采访中，肾科医生从18个做法，37%的描述经常讨论CM（“早期采用者”）。五个主题和相关子主题反映了影响肾科医生决定讨论CM的问题及其讨论方法：努力定义肾科医生的角色（确定治疗，灌输希望，改善患者症状），规避临终谈话（与预后的不确定性作斗争，担心情绪上的反弹，危及关系，剪裁信息），面对制度障碍（时间限制、护理协调、透析激励、各种CM方法的不适）、CM为“无护理”和道德困扰。肾科医生讨论CM的方法是由他们的角色的看法和CM的共同观点“不关心”形成的。他们追求CM的意愿受到提供者层面和机构层面的障碍以及老年患者后悔或受到透析伤害（道德困扰）的经验的影响。早期采用者经常讨论CM作为缓解道德痛苦的一种方式，而其他更有选择性地讨论CM的人则经历了更大的痛苦。由于对学术临床医生的过度抽样，参与者的观点可能最适合大型学术医疗中心。我们的研究结果澄清了道德困扰如何作为CM讨论的催化剂，并强调了美国CM使用率低的潜在干预点和机制。
Although dialysis may not provide a large survival benefit for older patients with kidney failure, few are informed about conservative management (CM). Barriers and facilitators to discussions about CM as well as nephrologists’ decisions to present the option of CM may vary within the nephrology provider community. Interview study of nephrologists National sample of US nephrologists sampled based on gender, years in practice, practice type, and region. Qualitative semi-structured interviews continued until thematic saturation. Thematic and narrative analysis of recorded and transcribed interviews. Among 35 semi-structured interviews with nephrologists from 18 practices, 37% described routinely discussing CM (“early adopters”). Five themes and related subthemes reflected issues that influence nephrologists’ decisions to discuss CM and their approaches to these discussions: struggling to define nephrologists’ roles (determining treatment, instilling hope, improving patient symptoms), circumventing end-of-life conversations (contending with prognostic uncertainty, fearing emotional backlash, jeopardizing relationships, tailoring information), confronting institutional barriers (time constraints, care coordination, incentives for dialysis, discomfort with varied CM approaches), CM as “no care”, and moral distress. Nephrologists’ approaches to CM discussions were shaped by perceptions of their roles and by a common view of CM as “no care”. Their willingness to pursue CM was influenced by provider-level and institutional-level barriers and experiences with older patients who regretted or had been harmed by dialysis (moral distress). Early adopters routinely discussed CM as a way of relieving moral distress, whereas others who were more selective in discussing CM experienced greater distress. Participants’ views are likely most transferable to large academic medical centers, due to oversampling of academic clinicians. Our findings clarify how moral distress serves as a catalyst for CM discussion and highlight points of intervention and mechanisms potentially underlying low CM use in the United States.
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影响因子：
13.2
作者：
Holley, JL;Carmody, SS;Arnold, RM
通讯作者：
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DOI：
10.2215/cjn.05960809
发表时间：
2010-02-01
影响因子：
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作者：
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DOI：
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通讯作者：
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DOI：
10.2215/cjn.02040606
发表时间：
2006-11-01
影响因子：
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作者：
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影响因子：
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作者：
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