臨牀透析 Vol.30 No.10(9)


特集名 高齢透析患者に対する個別化した医療と介護
題名 終末期医療:透析の非導入・継続中止・事前指示―いつ,どのようにして進めるべきか―
発刊年月 2014年 09月
著者 大平 整爾 札幌北クリニック
【 要旨 】 末期慢性腎不全患者は透析を選択すれば,その開始後に安定期を迎えてその人なりの社会復帰を果たす.しかし,種々の合併症の出現は完全には回避できず,一定期間後に日常生活の基本動作が困難か不能となる.この時期にいわゆる終末期ケアが,遅くとも開始されるべきと考える.担当医がもっとも苦慮する点は臨死期の患者の意向が不明であることで,事前指示(書)の必要性が高く,透析開始後病状の落ち着いた時期に患者に作成を勧めたい.一方で透析導入(開始)の決断は単に腎機能障害度にのみ依存せず,他臓器の障害度にも検討を加えたうえで,透析療法の効用度を見極めることが医療側と患者側に必要となる.日本透析医学会理事会が2014年3月28日に承認した「維持血液透析の開始と継続に関する意思決定プロセスについての提言」が,この問題で有用な指針となることを,提言作成に関わった一人として願いたい.
Theme Individualized treatment and care for elderly dialysis patients
Title End-of-life treatment/care : withholding dialysis, withdrawal of treatment and advance directives (When and how to proceed)
Author Seiji Ohira Sapporo Kita Clinic
[ Summary ] Approximately 30,000 maintenance dialysis patients die every year. The 2011 death toll was 28,768 and the top 3 causes of death were cardiac failure (26.7 %), infection (20.3 %) and malignant tumors (9.1 %). There is no data concerning withholding or withdrawal of care for dialysis in Japan. However, the number of patients dying due to 'suicide or refusal' is reported to be 0.7 %. Because the causes of death are so varied, the methods for terminal care must also be diverse. After initiation of dialysis and when stability has been achieved, return to a somewhat normal life may be realized. However, complications may arise which cannot be completely avoided. In time, the basic functions of daily life become difficult or impossible. Terminal care should be started at this time. A most troubling situation for physicians is when the intentions of the terminally ill patient are unknown. Advance directives are highly necessary and recommended. Their creation should be discussed with the patient when their condition is stable after having begun dialysis. Decisions for the introduction of dialysis do not depend on the level of renal dysfunction alone. Medical staffs, patients and family members must take into consideration the overall condition of the patient when deciding on the effectiveness of dialysis therapy.
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