#NephMadness 2020: Koncicki’s Pick for the Ethics Region – Dialysis for Patients at the End-of-Life

Posted onApril 27, 2020经过AJKDblog在韦德国际官网网址// 0评论

Holly Koncicki@hollymariemd

Holly Koncicki completed her medicine residency training at Mount Sinai Hospital, followed by completion of an integrated fellowship in nephrology and palliative medicine. She is currently appointed as Assistant Professor at the Icahn School of Medicine at Mount Sinai. Dr. Koncicki is working closely with the fellowship leadership at Mount Sinai in shaping the curriculum for the integrated nephrology and palliative care fellowship.

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Competitors for theEthics Region：

Policy-Driven Outcomes for DialysisvsPatient-Driven Choice for Dialysis

End-of-Life Care for Patients on DialysisvsDialysis for Patients at End-of-Life

这 ”生命尽头患者的透析” team has the potential to provide quite the upset in this year’s NephMadness tournament. No one is expecting this quiet team to go all the way. Who is this team? Let’s take a closer look.

这是一个充满梦想家的团队。他们有独特的技能，交流，其中许多人可能在一个名为“肾上腺词”的训练营中学到了这一点。尽管任何人都可以学习这种基本技能，但许多人并没有在奖学金期间缺乏标准化教育。该团队准备谈论几乎没有肾脏病学家的预后。

Here’s what they know: The growth of maintenance dialysis patients over the age of 75 has doubled in recent years. Adjusted mortality for patients on dialysis is nearly twice that of cancer and more than twice that of patients with heart failure or stroke. Five-year survival of patients on hemodialysis is estimated to be about 42%. A recent study of 400 incident dialysis patients over the age of 65 estimated 1-year mortality to be 54.5%.

患者想了解预后，以及患者认为的预后与实际的差异，这是惊人的。在一项研究中，询问透析患者的患者认为与健康状况相似的人居住了多长时间。回答有一半以上的人报告预期生存率> 10年，而实际生存期预计将<5年。这表明，尽管开始透析，但许多人面临不良结果的高风险，包括生存率有限。

在临终关怀中，有一个理论上的选择，即预后少于6个月，并且与其ESKD无关的终末诊断，尽管从逻辑上讲，这并不总是可行的。在终止生命末的患者呢，他们没有其他诊断可以入学，或者超过6个月但仍有有限的生存，并希望继续透析呢？否则，这些患者在接受临终关怀之前被迫停止透析治疗。

In terms of what our patients value, increased survival is actually not at the top of their list – other metrics such as independence take the top pick. Here is the big question: Is there another way to deliver dialysis at the end-of-life? And should dialysis treatments differ for patients with an expected prognosis of a year or less? This team thinks so.

Not many other teams can compare to their talent of eliciting patient goals and preferences, and this is where the team may run away with the game. Here’s their strategy: First, they discuss prognosis and goals of care. This is a time-consuming process but the reward is tremendous. Eliciting what is most important to the patient will help the provider make recommendations on how to align patient-centered metrics with their dialysis treatments, rather than focusing on standard dialysis care metrics.

Then this team really pulls out a playbook that many have never seen before. As they try to focus on patient-centered metrics, such as symptom management and health-related quality-of-life, they may do things like accepting a central venous catheter in lieu of pursuing an AVG or AVF in the patient (stunned silence from the crowd). They may liberalize a patient’s diet, permitting hyperphosphatemia and limit medications to allow for hyperparathyroidism (crowd gasps!). They may focus more on optimization of volume status and with that, they may decrease treatments to just twice per week, accepting lower clearances (opposing coach throws hands up in the air).

令人惊讶的是，这支球队能够实现如此精致的技能，尤其是因为他们的比赛方式，他们有失去报销的风险。是的，这是一个很大的障碍，尽管这种策略对于患者护理非常重要，但其他团队犹豫不决，因为CMS付款不是基于这些以患者为中心的指标。就像我说的那样，这个团队充满了梦想家……他们认为现在是时候了。也许如果他们在本次比赛中取得胜利，人们将开始关注，并提出棘手的问题，以吸引更多的团队遵循他们的领先优势。

– Guest Post written byHolly Koncicki@hollymariemd

与AJKD博客上的所有内容一样，表达的意见是每个帖子的伟德国际注册送25作者的观点，不一定会得到AJKD博客，AJKD，国家肾脏基金会，Elsevier或任何其他实体的共享或认可，除非明确说明。