Advance Care Planning Among Older Adults With Advanced Non-Dialysis-Dependent CKD and Their Care Partners: Perceptions Versus Reality?
Advance Care Planning Among Older Adults With Advanced Non-Dialysis-Dependent CKD and Their Care Partners: Perceptions Versus Reality?
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DOI：
10.1016/j.xkme.2019.11.002
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发表时间：
2020-03-01
期刊：
影响因子：
3.9
通讯作者：
Ladin, Keren
中科院分区：
文献类型：
--
作者：
Oskoui, Tira;Pandya, Renuka;Ladin, Keren
理由与目的：老年晚期慢性肾脏疾病（CKD）患者在生命结束时使用重症监护，比癌症或心脏病患者更频繁地在医院死亡。预先护理计划（ACP）有助于使治疗与患者偏好相一致，并改善以患者为中心的护理，然而，老年CKD患者及其护理伙伴的ACP质量和经验仍然不完全清楚，特别是在非透析依赖人群中。研究设计：对70岁及以上非透析依赖型CKD 4期或5期患者及其自我确认的护理伙伴进行访谈式调查。环境和参与者：42名参与者（31名患者，11名护理伙伴）在大波士顿地区的2个临床站点。结果：完成预先指示和自我报告的感知、偏好和ACP经验。分析方法：对患者和护理伙伴调查进行描述性分析。McNemar试验分析比较患者和护理伙伴的反应。结果：大多数患者有书面预先指示（64%）和代理决策者（81%）。尽管患者对临床医生的判断有积极的看法和高度的信任，但很少（16%）的患者实际上与他们的肾脏科医生讨论了维持生命治疗的偏好。很少有ACP讨论包括反映高质量ACP的组成部分：16%的患者被问及他们对临终关怀的价值观，7%的患者讨论了决策能力和健康状况下降时是否同意护理的问题。当出现两种假设情景（中风/心脏病发作或痴呆）时，几乎所有患者和护理伙伴都报告说，他们更倾向于舒适护理，而不是延迟死亡。护理伙伴比患者更有可能报告他们与临床团队进行了反映高质量ACP的讨论。限制：单一大都市区；大多数患者没有确定护理伙伴；无反应偏倚和小样本量。结论：患者通常认为他们的临床医生理解他们的临终愿望，尽管他们没有参与ACP对话，使他们的愿望知道。改善临床ACP沟通可能会使临终治疗更好地符合患者的目标。
Rationale & Objective: Older patients with advanced chronic kidney disease (CKD) use intensive care at the end of life and die in a hospital more frequently than patients with cancer or heart disease. Advance care planning (ACP) can help align treatment with patient preferences and improve patient-centered care, yet ACP quality and experiences among older patients with CKD and their care partners remain incompletely understood, particularly among the non-dialysis-dependent population.Study Design: In-person interviewer-administered surveys of patients 70 years and older with non-dialysis-dependent CKD stage 4 or 5 and their self-identified care partners.Setting & Participants: 42 participants (31 patients, 11 care partners) at 2 clinical sites in greater Boston.Outcomes: Completion of advance directives and self-reported perceptions, preferences, and experiences of ACP.Analytical Approach: Descriptive analysis of patient and care partner surveys. McNemar test analysis to compare patient and care partner responses.Results: Most patients had written advance directives (64%) and surrogate decision makers (81%). Although patients reported positive perceptions and high trust in their clinicians' judgment, few (16%) had actually discussed preferences for life-sustaining treatment with their nephrologists. Few ACP discussions included components reflective of high-quality ACP: 16% of patients had been asked about their values concerning end-of-life care and 7% had discussed issues of decision-making capacity and consent to care should their health decline. When presented with 2 hypothetical scenarios (stroke/heart attack or dementia), nearly all patients and care partners reported a preference for comfort care over delaying death. Care partners were more likely than patients to report that they had experienced discussion components reflective of high-quality ACP with the clinical team.Limitations: Single metropolitan area; most patients did not identify a care partner; nonresponse bias and small sample size.Conclusions: Patients often believed that their clinicians understood their end-of-life wishes despite not having engaged in ACP conversations that would make those wishes known. Improving clinical ACP communication may result in end-of-life treatment that better aligns with patient goals.