前一篇文章寫的是大綱,其實除了看大綱之外,還是得看內文,才知道為什麼指引會這樣訂定,接下來,我會分幾篇文章來寫討論內容:
一、開始透析的時機:
1.1 當慢性腎臟病患者的腎功能剩下 30分以下時 (GFR <30 ml/min/1.73m2),應該要提供患者充分的資訊,以因應將來腎臟衰竭時,所要面對的種種問題,如:腎臟替代療法的種類(腎臟移植、血液透析、腹膜透析、或安寧支持療法)、各類治療的優點與缺點。此外,照顧者與家人也應該參予學習這些資訊,以利於患者與家屬在做各種選擇時,能充分按照自己之偏好或狀況,來做決定。
準則 1.1 的討論:
不管是患者本身,或者他們的照顧者、家人,都需要更充足的時間,與更多的資訊,好讓他們思考與面對可能的生活變化,我們知道,腎臟衰竭之後,有四種可能的應對方式,血液透析、腹膜透析、腎臟移植、與安寧照護 (前三種統稱腎臟替代療法)。每一種替代腎臟的方式,都有不一樣的生活型態、限制、照顧者的負擔程度、或面對的難題,而美國腎臟學會認為,過去我們在事前教育患者這個部份,做的不夠。
大部分的患者,是照著醫生給他的建議,開始接受某種腎臟替代療法,但可能會有人後來卻後悔了這樣的選擇。另一個問題,是在於醫病雙方都對於這個問題難以啟齒、避談,原因也很明顯,醫師擔憂引起患者的負面情緒反應,而患者對於這樣的壞消息,往往傾向忽略不談,如此一來,溝通怎麼能夠順利呢?
因此,一方面要避免患者負面情緒,一方面又得要讓患者了解這些所有治療選項,及早開始介入,用正向的、個人化的方式,預期要花比之前更久的時間,而且要讓患者周邊的人也幫忙,才能真的讓患者認識這個無可避免的課題。這樣接受完整教育的患者,除了更能理解問題之外,日後的死亡率也能下降一半,可以說心理和生理都有好處。
雖然,沒有證據說腎功能剩下幾分的時候,就要開始介入教育,而且每個病人腎功能變化的速度不一,介入的時機很難去規範,訂的太早也沒意義,更不能訂的太晚,會讓溝通的過程太趕太急,因此,折衷定在腎功能剩下 30 (GFR <30 ml/min/1.73m2)的時候,提醒臨床醫師,此時應該著手開始與患者溝通的工作了。
再者,關於照護的教育,不應該只限於開始透析之前,而是要連透析之後都持續的給予適時的協助,這裡一段話與各位共勉:
“The purpose of dialysis is not solely prolongation of life but rather promotion of living”
透析的目的不僅僅是延長生命而已,更重要的是讓生命活的更好
個人想法:
透析是一種生活方式,雖然是不得已,但是只要努力學習適應它,生命還是可以很精彩。事前討論病情,在台灣還是需要努力,尤其是在非常趕的有限門診時間內,要做非常充分的諮詢討論,實在難度很高,希望我們的醫療環境,能讓每個患者都能有足夠的時間,為將來做好準備。
{2147300:2QFRVJ5V}naturedefaultascno1945%7B%22status%22%3A%22success%22%2C%22updateneeded%22%3Afalse%2C%22instance%22%3A%22zotpress-e1addb5f18c63636ab2e47999ed1929a%22%2C%22meta%22%3A%7B%22request_last%22%3A0%2C%22request_next%22%3A0%2C%22used_cache%22%3Atrue%7D%2C%22data%22%3A%5B%7B%22key%22%3A%222QFRVJ5V%22%2C%22library%22%3A%7B%22id%22%3A2147300%7D%2C%22meta%22%3A%7B%22creatorSummary%22%3A%22National%20Kidney%20Foundation%22%2C%22parsedDate%22%3A%222015-11%22%2C%22numChildren%22%3A1%7D%2C%22bib%22%3A%22%3Cdiv%20class%3D%5C%22csl-bib-body%5C%22%20style%3D%5C%22line-height%3A%202%3B%20%5C%22%3E%5Cn%20%20%3Cdiv%20class%3D%5C%22csl-entry%5C%22%20style%3D%5C%22clear%3A%20left%3B%20%5C%22%3E%5Cn%20%20%20%20%3Cdiv%20class%3D%5C%22csl-left-margin%5C%22%20style%3D%5C%22float%3A%20left%3B%20padding-right%3A%200.5em%3B%20text-align%3A%20right%3B%20width%3A%201em%3B%5C%22%3E1.%3C%5C%2Fdiv%3E%3Cdiv%20class%3D%5C%22csl-right-inline%5C%22%20style%3D%5C%22margin%3A%200%20.4em%200%201.5em%3B%5C%22%3ENational%20Kidney%20Foundation.%20KDOQI%20Clinical%20Practice%20Guideline%20for%20Hemodialysis%20Adequacy%3A%202015%20Update.%20%3Ci%3EAm.%20J.%20Kidney%20Dis.%3C%5C%2Fi%3E%20%3Cb%3E66%3C%5C%2Fb%3E%2C%20884%26%23x2013%3B930%20%282015%29.%3C%5C%2Fdiv%3E%5Cn%20%20%3C%5C%2Fdiv%3E%5Cn%3C%5C%2Fdiv%3E%22%2C%22data%22%3A%7B%22itemType%22%3A%22journalArticle%22%2C%22title%22%3A%22KDOQI%20Clinical%20Practice%20Guideline%20for%20Hemodialysis%20Adequacy%3A%202015%20Update%22%2C%22creators%22%3A%5B%7B%22creatorType%22%3A%22author%22%2C%22name%22%3A%22National%20Kidney%20Foundation%22%7D%5D%2C%22abstractNote%22%3A%22The%20National%20Kidney%20Foundation%27s%20Kidney%20Disease%20Outcomes%20Quality%20Initiative%20%28KDOQI%29%20has%20provided%20evidence-based%20guidelines%20for%20all%20stages%20of%20chronic%20kidney%20disease%20%28CKD%29%20and%20related%20complications%20since%201997.%20The%202015%20update%20of%20the%20KDOQI%20Clinical%20Practice%20Guideline%20for%20Hemodialysis%20Adequacy%20is%20intended%20to%20assist%20practitioners%20caring%20for%20patients%20in%20preparation%20for%20and%20during%20hemodialysis.%20The%20literature%20reviewed%20for%20this%20update%20includes%20clinical%20trials%20and%20observational%20studies%20published%20between%202000%20and%20March%202014.%20New%20topics%20include%20high-frequency%20hemodialysis%20and%20risks%3B%20prescription%20flexibility%20in%20initiation%20timing%2C%20frequency%2C%20duration%2C%20and%20ultrafiltration%20rate%3B%20and%20more%20emphasis%20on%20volume%20and%20blood%20pressure%20control.%20Appraisal%20of%20the%20quality%20of%20the%20evidence%20and%20the%20strength%20of%20recommendations%20followed%20the%20Grading%20of%20Recommendation%20Assessment%2C%20Development%2C%20and%20Evaluation%20%28GRADE%29%20approach.%20Limitations%20of%20the%20evidence%20are%20discussed%20and%20specific%20suggestions%20are%20provided%20for%20future%20research.%22%2C%22date%22%3A%22Nov%202015%22%2C%22language%22%3A%22eng%22%2C%22DOI%22%3A%2210.1053%5C%2Fj.ajkd.2015.07.015%22%2C%22ISSN%22%3A%221523-6838%22%2C%22url%22%3A%22%22%2C%22collections%22%3A%5B%5D%2C%22dateModified%22%3A%222015-12-23T07%3A08%3A28Z%22%7D%7D%5D%7D 1.
National Kidney Foundation. KDOQI Clinical Practice Guideline for Hemodialysis Adequacy: 2015 Update. Am. J. Kidney Dis. 66, 884–930 (2015).