PDF(Pubmed)
Abstract：
BACKGROUND: Hospice care leads to improved patient and family outcomes. Hospice use among older adults with end-stage kidney disease (ESKD) is markedly lower than among older adults with other serious illnesses, and the majority of those with ESKD who use hospice enroll in the last days of life. Here, our aim was to explore barriers to timely receipt of high-quality hospice care for older adults with ESKD.
METHODS: Utilizing a qualitative study design, we conducted a secondary analysis focused on hospice, a theme that we identified in our larger overarching study that involved semi-structured interviews with 20 nephrologists in the United States focused on treatment decision-making in older adults with advanced chronic kidney disease. We analyzed the interview transcripts using emergent thematic analysis to develop an understanding of barriers to high-quality hospice.
RESULTS: With a couple notable exceptions, nephrologists voiced general support for the concept of hospice, but few recalled patients of theirs who had received hospice. Nephrologists\' interviews revealed two interrelated contributors to the lack of timely access to high-quality hospice care for seriously ill older adults with ESKD: (1) nephrologists view dialysis and hospice as mutually exclusive models of care; (2) nephrologists feel unsure who should manage hospice care for patients with ESKD. The first contributor was rooted in nephrologists\' narrow vision of when to consider hospice (informed, in part, by policy barriers) and, in a couple of cases, strong discomfort with hospice. The second stemmed from nephrologists\' belief that neither they nor hospice are adequately prepared to provide hospice care for ESKD.
CONCLUSIONS: Our findings suggest that, in addition to Medicare policy change, nephrologists need to receive more training in primary palliative care skills including in indications for hospice, initiating conversations about hospice with patients, and collaborating with hospice clinicians to care for these vulnerable patients.
METHODS: Utilizing a qualitative study design, we conducted a secondary analysis focused on hospice, a theme that we identified in our larger overarching study that involved semi-structured interviews with 20 nephrologists in the United States focused on treatment decision-making in older adults with advanced chronic kidney disease. We analyzed the interview transcripts using emergent thematic analysis to develop an understanding of barriers to high-quality hospice.
RESULTS: With a couple notable exceptions, nephrologists voiced general support for the concept of hospice, but few recalled patients of theirs who had received hospice. Nephrologists\' interviews revealed two interrelated contributors to the lack of timely access to high-quality hospice care for seriously ill older adults with ESKD: (1) nephrologists view dialysis and hospice as mutually exclusive models of care; (2) nephrologists feel unsure who should manage hospice care for patients with ESKD. The first contributor was rooted in nephrologists\' narrow vision of when to consider hospice (informed, in part, by policy barriers) and, in a couple of cases, strong discomfort with hospice. The second stemmed from nephrologists\' belief that neither they nor hospice are adequately prepared to provide hospice care for ESKD.
CONCLUSIONS: Our findings suggest that, in addition to Medicare policy change, nephrologists need to receive more training in primary palliative care skills including in indications for hospice, initiating conversations about hospice with patients, and collaborating with hospice clinicians to care for these vulnerable patients.
摘要：
背景：临终关怀可改善患者和家庭预后。终末期肾病（ESKD）老年人的临终关怀使用率明显低于其他严重疾病的老年人。大多数使用临终关怀的ESKD患者在生命的最后几天注册。这里,我们的目的是探索ESKD老年人及时接受高质量临终关怀的障碍.
方法：利用定性研究设计，我们对临终关怀进行了二次分析，我们在更大的总体研究中确定了一个主题,该研究涉及对美国20名肾脏病学家的半结构化访谈,重点关注患有晚期慢性肾脏病的老年人的治疗决策.我们使用紧急主题分析对访谈笔录进行了分析，以了解高质量临终关怀的障碍。
结果：除了几个值得注意的例外，肾脏病学家表示普遍支持临终关怀的概念，但很少有人回忆起他们接受过临终关怀的病人。肾脏科医师的访谈揭示了两个相互关联的因素，导致患有ESKD的重病老年人无法及时获得高质量的临终关怀护理：（1）肾脏科医师认为透析和临终关怀是相互排斥的护理模式；（2）肾脏科医师不确定谁应该管理ESKD患者的临终关怀护理。第一个贡献者植根于肾病学家对何时考虑临终关怀的狭隘视野(知情，在某种程度上,通过政策障碍)和，在几个案例中，对临终关怀的强烈不适。第二个原因是肾脏病学家认为他们和临终关怀医院都没有充分准备为ESKD提供临终关怀。
结论：我们的研究结果表明，除了医疗保险政策的改变，肾脏病学家需要接受更多的初级姑息治疗技能培训，包括临终关怀的适应症，与病人开始关于临终关怀的对话，并与临终关怀临床医生合作照顾这些脆弱的患者。
方法：利用定性研究设计，我们对临终关怀进行了二次分析，我们在更大的总体研究中确定了一个主题,该研究涉及对美国20名肾脏病学家的半结构化访谈,重点关注患有晚期慢性肾脏病的老年人的治疗决策.我们使用紧急主题分析对访谈笔录进行了分析，以了解高质量临终关怀的障碍。
结果：除了几个值得注意的例外，肾脏病学家表示普遍支持临终关怀的概念，但很少有人回忆起他们接受过临终关怀的病人。肾脏科医师的访谈揭示了两个相互关联的因素，导致患有ESKD的重病老年人无法及时获得高质量的临终关怀护理：（1）肾脏科医师认为透析和临终关怀是相互排斥的护理模式；（2）肾脏科医师不确定谁应该管理ESKD患者的临终关怀护理。第一个贡献者植根于肾病学家对何时考虑临终关怀的狭隘视野(知情，在某种程度上,通过政策障碍)和，在几个案例中，对临终关怀的强烈不适。第二个原因是肾脏病学家认为他们和临终关怀医院都没有充分准备为ESKD提供临终关怀。
结论：我们的研究结果表明，除了医疗保险政策的改变，肾脏病学家需要接受更多的初级姑息治疗技能培训，包括临终关怀的适应症，与病人开始关于临终关怀的对话，并与临终关怀临床医生合作照顾这些脆弱的患者。
