Matters of Life and Death: Why Do Older Patients Choose Conservative Management?
Matters of Life and Death: Why Do Older Patients Choose Conservative Management?
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生与死事件：为什么老年患者选择保守管理？
DOI：
10.1159/000504692
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发表时间：
2020
影响因子：
4.2
通讯作者：
中科院分区：
文献类型：
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作者：
尽管许多患有终末期肾病且预后有限的老年患者更喜欢保守治疗 (CM)，但这种治疗在美国并未得到广泛实施。此外，美国缺乏报道有关晚期慢性肾脏病 (CKD) CM 共同决策的临床经验的文献。我们描述了 2016 年至 2017 年期间在罗切斯特大学医学中心 CKD 诊所选择 CM 的 13 名患者的临床经验。主要结果包括：(1) 选择 CM 的原因，(2) 完成预先指示，(3) 死亡地点，以及 (4) 使用临终关怀服务。根据对电子病历的审查，患者选择 CM 的原因分为 4 大类。由 2 名评审员进行的回顾性图表评审确定了预先护理计划、临终关怀转诊和死亡地点的状态。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；他们渴望有尊严的生活结束；以及保护家人免于看到他们受苦的意图，基于他们自己之前目睹亲戚接受透析的记忆。共有 8 名患者死亡：全部接受临终关怀服务，其中 6 人在家中死亡，1 人在疗养院死亡，1 人在医院死亡。 100% 的病例完成了预先护理计划。与初级保健医生合作管理症状。除了合并症和有限的预后之外，患者选择 CM 的决定还受到他们的价值观和既往透析经验的影响。在美国促进 CM 的选择需要对临床医生进行初级姑息治疗能力的培训，包括沟通和决策技能以及基本症状管理能力。
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.