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姑息治疗：终末期肾病

Author
Jean L Holley, MD, FACP
Section Editors
Jeffrey S Berns, MD
R Sean Morrison, MD
Deputy Editor
Alice M Sheridan, MD
Translators
李平, 研究员，主任医师，教授

引言

终末期肾病(end-stage renal disease, ESRD)的老年人口日益增加，美国尤其明显，因此需要肾病医师关注有关姑息治疗的问题[1-8]。例如，肾病医师协会(Renal Physicians Association, RPA)主办了有关不给予透析和停止透析的循证指南[9]，英国专家共识小组(United Kingdom Expert Consensus Group)发布了慢性肾脏病(chronic kidney disease, CKD)临终成人的症状管理指南[10]。

近20%的透析患者于死亡前停止透析，而且越来越多的年长患者选择不开始透析，部分原因是结局不良和透析时功能状态下降[11-14]，因此所有肾病医师可能都会参与到ESRD和CKD患者的临终护理中来。然而，总的来说，医生们没接受过充分的姑息治疗训练，且常对治疗生命垂危的患者感觉没把握[15,16]。例如，在一项针对美国和加拿大医生的调查中，360名肾病医师中仅约40%表示对做出临终决策做好了充分准备[16]。尽管意识到姑息治疗在ESRD护理中的重要性，但肾病医疗人员仍对这些方面的临床治疗没把握且缺乏充分训练[17,18]。 (参见“停止透析和不予以透析”)

针对CKD患者的姑息治疗始于确诊，并维持至患者去世。随着肾脏病的进展，姑息治疗的重要性也随时间的推移而增加，且是获得“善终”的必要环节。透析机构的工作人员应参与姑息治疗且必须认识到他们在预立医疗自主计划、疼痛和症状管理和丧亡支持方面的责任[4,9,19-22]。英国一项姑息治疗全国调查再次表明了改善ESRD护理中姑息治疗的机会，并促使作者们提议肾脏病姑息治疗方案的指南[23]。

本专题将会讨论对于停止透析或选择不开始透析的患者其治疗中通常需要注意的方面。本文也将阐明此类患者的姑息治疗原则和镇痛使用指南。

姑息治疗的原则

姑息治疗是指对重病患者及其家庭的躯体、心理、社会、精神和存在需求进行综合管理[24]。姑息治疗的目标是通过缓解痛苦、控制症状、恢复功能，同时保持对个人、文化和精神信仰及实践的敏感性来尽可能获得最佳生存质量[24]。在严重疾患的整个病程中，姑息治疗越来越优先于针对疾病的治疗，并最终专注于濒死过程。

            

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Literature review current through: 2017-06 . | This topic last updated: 2016-05-11.
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