UpToDate
Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate®

停止透析和不予以透析

Authors
Tony Dash, MD
Lionel U Mailloux, MD, FACP
Section Editors
Jeffrey S Berns, MD
J Andrew Billings, MD
Deputy Editor
Alice M Sheridan, MD
Translators
李春梅, 副主任医师

引言

肾脏病专科执业医师经常面临做出停止透析和不予以透析的决定。这种决定涉及复杂的伦理、社会心理及经济问题，这些问题变得越来越重要，其驱动因素为患者及其家人关于生命终止决定的意识增强和管理式医疗与合理定量配给资源时代的到来[1-3]。

在美国，肾脏替代治疗的普遍可用性促使肾脏专科医师考虑将其用于每一个可能需要肾脏替代治疗的患者。然而，如果患者拒绝开始或继续透析，肾脏专科医师可能认为其为一种“失败”。由于患者和医生越来越多地使用预先指示，以及追求值得赞赏的目标是有尊严的死亡和生存质量，现在放弃透析更加多见。然而，并非所有医生都愿意推荐停止透析而着重采取安慰措施，尤其是在透析设备可用且不需要定量配给治疗时。这些问题可能是医生、患者及其家人出现矛盾的原因[4]。

放弃透析治疗的临床方面将在此讨论。终末期肾病(end-stage renal disease, ESRD)患者治疗相关一般伦理问题的总结参见其他专题。 (参见“在终末期肾病患者治疗中的伦理问题”)

定义

停止透析是指停止维持性透析。不予以透析的定义为急性肾脏病或慢性肾脏病(chronic kidney disease, CKD)患者在还未开始透析的情况下，不进行透析。

基于美国、加拿大及地区的数据，停止透析是加拿大ESRD患者中第二最常见的死因(仅次于心血管疾病)，是美国ESRD患者中第三最常见的死因(仅次于心血疾病管和感染性疾病)[3,5-7]。

                     

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: 2017-06 . | This topic last updated: 2016-03-28.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
References
Top
  1. Levinsky NG. The organization of medical care. Lessons from the Medicare end stage renal disease program. N Engl J Med 1993; 329:1395.
  2. Klahr S. Rationing of health care and the end-stage renal disease program. Am J Kidney Dis 1990; 16:392.
  3. United States Renal Data System. USRDS 2009 Annual Data Report. U.S. Department of Health and Human Services. The National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD. Am J Kidney Dis 2010; 55(Suppl 1):S1.
  4. Moss AH. 'At least we do not feel guilty': Managing conflict with families over dialysis discontinuation. Am J Kidney Dis 1998; 31:868.
  5. Canadian Organ Replacement Register. 1993 Annual Report, Canadian Institute for Health Information, Don Mills, Ontario, Canada, March 1995.
  6. Bleyer AJ, Tell GS, Evans GW, et al. Survival of patients undergoing renal replacement therapy in one center with special emphasis on racial differences. Am J Kidney Dis 1996; 28:72.
  7. Mailloux LU, Bellucci AG, Napolitano B, et al. Death by withdrawal from dialysis: a 20-year clinical experience. J Am Soc Nephrol 1993; 3:1631.
  8. Moss AH. Shared decision-making in dialysis: the new RPA/ASN guideline on appropriate initiation and withdrawal of treatment. Am J Kidney Dis 2001; 37:1081.
  9. Moss AH. Revised dialysis clinical practice guideline promotes more informed decision-making. Clin J Am Soc Nephrol 2010; 5:2380.
  10. http://www.renalmd.org/Search.aspx?searchtext=shared decision making&folderid=0&searchfor=all&orderby=rank&orderdirection=descending (Accessed on April 05, 2013).
  11. Singer PA. Nephrologists' experience with and attitudes towards decisions to forego dialysis. The End-Stage Renal Disease Network of New England. J Am Soc Nephrol 1992; 2:1235.
  12. Hirsch DJ, West ML, Cohen AD, Jindal KK. Experience with not offering dialysis to patients with a poor prognosis. Am J Kidney Dis 1994; 23:463.
  13. Morton RL, Turner RM, Howard K, et al. Patients who plan for conservative care rather than dialysis: a national observational study in Australia. Am J Kidney Dis 2012; 59:419.
  14. Sekkarie MA, Moss AH. Withholding and withdrawing dialysis: the role of physician specialty and education and patient functional status. Am J Kidney Dis 1998; 31:464.
  15. Lowance DC. Factors and guidelines to be considered in offering treatment to patients with end-stage renal disease: a personal opinion. Am J Kidney Dis 1993; 21:679.
  16. Moss AH. To use dialysis appropriately: the emerging consensus on patient selection guidelines. Adv Ren Replace Ther 1995; 2:175.
  17. Lambie M, Rayner HC, Bragg-Gresham JL, et al. Starting and withdrawing haemodialysis--associations between nephrologists' opinions, patient characteristics and practice patterns (data from the Dialysis Outcomes and Practice Patterns Study). Nephrol Dial Transplant 2006; 21:2814.
  18. Moss AH, Stocking CB, Sachs GA, Siegler M. Variation in the attitudes of dialysis unit medical directors toward decisions to withhold and withdraw dialysis. J Am Soc Nephrol 1993; 4:229.
  19. Eiser AR, Seiden DJ. Discontinuing dialysis in persistent vegetative state: the roles of autonomy, community, and professional moral agency. Am J Kidney Dis 1997; 30:291.
  20. Devita M, Grenvik A. Foregoing life-sustaining therapy in intensive care. In: Textbook of Critical Care, Ayres S, Grenvik A, Holbrook P, Shoemaker W (Eds), WB Saunders, Philadelphia 1995. p.1802.
  21. Moosa MR, Kidd M. The dangers of rationing dialysis treatment: the dilemma facing a developing country. Kidney Int 2006; 70:1107.
  22. O'Connor NR, Kumar P. Conservative management of end-stage renal disease without dialysis: a systematic review. J Palliat Med 2012; 15:228.
  23. Brown MA, Collett GK, Josland EA, et al. CKD in elderly patients managed without dialysis: survival, symptoms, and quality of life. Clin J Am Soc Nephrol 2015; 10:260.
  24. Smith C, Da Silva-Gane M, Chandna S, et al. Choosing not to dialyse: evaluation of planned non-dialytic management in a cohort of patients with end-stage renal failure. Nephron Clin Pract 2003; 95:c40.
  25. Wong CF, McCarthy M, Howse ML, Williams PS. Factors affecting survival in advanced chronic kidney disease patients who choose not to receive dialysis. Ren Fail 2007; 29:653.
  26. Chandna SM, Da Silva-Gane M, Marshall C, et al. Survival of elderly patients with stage 5 CKD: comparison of conservative management and renal replacement therapy. Nephrol Dial Transplant 2011; 26:1608.
  27. Murtagh FE, Marsh JE, Donohoe P, et al. Dialysis or not? A comparative survival study of patients over 75 years with chronic kidney disease stage 5. Nephrol Dial Transplant 2007; 22:1955.
  28. Couchoud C, Labeeuw M, Moranne O, et al. A clinical score to predict 6-month prognosis in elderly patients starting dialysis for end-stage renal disease. Nephrol Dial Transplant 2009; 24:1553.
  29. Hussain JA, Mooney A, Russon L. Comparison of survival analysis and palliative care involvement in patients aged over 70 years choosing conservative management or renal replacement therapy in advanced chronic kidney disease. Palliat Med 2013; 27:829.
  30. Joly D, Anglicheau D, Alberti C, et al. Octogenarians reaching end-stage renal disease: cohort study of decision-making and clinical outcomes. J Am Soc Nephrol 2003; 14:1012.
  31. Carson RC, Juszczak M, Davenport A, Burns A. Is maximum conservative management an equivalent treatment option to dialysis for elderly patients with significant comorbid disease? Clin J Am Soc Nephrol 2009; 4:1611.
  32. Cohen LM, Germain MJ, Poppel DM. Practical considerations in dialysis withdrawal: "to have that option is a blessing". JAMA 2003; 289:2113.
  33. ESRD network of New England. 2001 Annual Report to the Centers for Medicare and Medicaid Services. New Haven, Conn: Tyco Printers; July 2002; 60.
  34. Murtagh F, Cohen LM, Germain MJ. Dialysis discontinuation: quo vadis? Adv Chronic Kidney Dis 2007; 14:379.
  35. Bajwa K, Szabo E, Kjellstrand CM. A prospective study of risk factors and decision making in discontinuation of dialysis. Arch Intern Med 1996; 156:2571.
  36. Moss AH. Dialysis decisions and the elderly. Clin Geriatr Med 1994; 10:463.
  37. Leggat JE Jr, Bloembergen WE, Levine G, et al. An analysis of risk factors for withdrawal from dialysis before death. J Am Soc Nephrol 1997; 8:1755.
  38. Cohen LM, Germain M, Woods A, et al. Patient attitudes and psychological considerations in dialysis discontinuation. Psychosomatics 1993; 34:395.
  39. Bloembergen WE, Port FK, Mauger EA, Wolfe RA. A comparison of cause of death between patients treated with hemodialysis and peritoneal dialysis. J Am Soc Nephrol 1995; 6:184.
  40. Bloembergen WE, Port FK, Mauger EA, Wolfe RA. A comparison of mortality between patients treated with hemodialysis and peritoneal dialysis. J Am Soc Nephrol 1995; 6:177.
  41. Nelson CB, Port FK, Wolfe RA, Guire KE. The association of diabetic status, age, and race to withdrawal from dialysis. J Am Soc Nephrol 1994; 4:1608.
  42. Port FK, Wolfe RA, Hawthorne VM, Ferguson CW. Discontinuation of dialysis therapy as a cause of death. Am J Nephrol 1989; 9:145.
  43. Neu S, Kjellstrand CM. Stopping long-term dialysis. An empirical study of withdrawal of life-supporting treatment. N Engl J Med 1986; 314:14.
  44. Kurella M, Kimmel PL, Young BS, Chertow GM. Suicide in the United States end-stage renal disease program. J Am Soc Nephrol 2005; 16:774.
  45. Fissell RB, Bragg-Gresham JL, Lopes AA, et al. Factors associated with "do not resuscitate" orders and rates of withdrawal from hemodialysis in the international DOPPS. Kidney Int 2005; 68:1282.
  46. Cohen LM, Germain M, Poppel DM, et al. Dialysis discontinuation and palliative care. Am J Kidney Dis 2000; 36:140.
  47. O'Connor NR, Dougherty M, Harris PS, Casarett DJ. Survival after dialysis discontinuation and hospice enrollment for ESRD. Clin J Am Soc Nephrol 2013; 8:2117.
  48. Anderson F, Downing GM, Hill J, et al. Palliative performance scale (PPS): a new tool. J Palliat Care 1996; 12:5.
  49. Cohen LM, McCue JD, Germain M, Kjellstrand CM. Dialysis discontinuation. A 'good' death? Arch Intern Med 1995; 155:42.
  50. Tobe SW, Senn JS. Foregoing renal dialysis: a case study and review of ethical issues. The End-Stage Renal Disease Group. Am J Kidney Dis 1996; 28:147.
  51. Lowance DC. Withdrawal from dialysis: an ethical perspective. Kidney Int 1988; 34:124.
  52. Swartz RD, Perry E, Schneider C, et al. The option to withdraw from chronic dialysis treatment. Adv Ren Replace Ther 1994; 1:264.
  53. Cruzan v Director, Missouri Department of Health, 497, US 261, 1990.
  54. Pickering JH. Death and the law: What is the right to die? Eleventh Annual Leon and Josephine Winkelman Lecture. University of Michigan School of Social Work. Ann Arbor, MI 1989.
  55. Kerridge I, Lowe M, Mitchell K. Competent patients, incompetent decisions. Ann Intern Med 1995; 123:878.
  56. Singer PA, Thiel EC, Naylor CD, et al. Life-sustaining treatment preferences of hemodialysis patients: implications for advance directives. J Am Soc Nephrol 1995; 6:1410.
  57. Holley JL, Nespor S, Rault R. The effects of providing chronic hemodialysis patients written material on advance directives. Am J Kidney Dis 1993; 22:413.
  58. Holley JL, Nespor S, Rault R. Chronic in-center hemodialysis patients' attitudes, knowledge, and behavior towards advance directives. J Am Soc Nephrol 1993; 3:1405.
  59. Holley JL, Foulks CJ, Moss AH. Nephrologists' reported attitudes about factors influencing recommendations to initiate or withdraw dialysis. J Am Soc Nephrol 1991; 1:1284.
  60. Mendelssohn DC, Singer PA. Advance directives in dialysis. Adv Ren Replace Ther 1994; 1:240.
  61. Perry E, Buck C, Newsome J, et al. Dialysis staff influence patients in formulating their advance directives. Am J Kidney Dis 1995; 25:262.
  62. Perry LD, Nicholas D, Molzahn AE, Dossetor JB. Attitudes of dialysis patients and caregivers regarding advance directives. ANNA J 1995; 22:457.
  63. Hines SC, Glover JJ, Holley JL, et al. Dialysis patients' preferences for family-based advance care planning. Ann Intern Med 1999; 130:825.
  64. Sehgal A, Galbraith A, Chesney M, et al. How strictly do dialysis patients want their advance directives followed? JAMA 1992; 267:59.
  65. Swartz RD, Perry E. Advance directives are associated with "good deaths" in chronic dialysis patients. J Am Soc Nephrol 1993; 3:1623.
  66. A controlled trial to improve care for seriously ill hospitalized patients. The study to understand prognoses and preferences for outcomes and risks of treatments (SUPPORT). The SUPPORT Principal Investigators. JAMA 1995; 274:1591.
  67. Lo B. Improving care near the end of life. Why is it so hard? JAMA 1995; 274:1634.
  68. Kjellstrand CM. Giving life, giving death: ethical problems of high-technology medicine. Acta Med Scand Suppl 1988; 725:1.
  69. Berman E, Merz JF, Rudnick M, et al. Religiosity in a hemodialysis population and its relationship to satisfaction with medical care, satisfaction with life, and adherence. Am J Kidney Dis 2004; 44:488.