臨牀透析 Vol.32 No.8(2-8)


特集名 認知症と透析医療
題名 認知症患者の終末期サポート―最終的手段としての透析中止を含めて
発刊年月 2016年 07月
著者 大平 整爾 札幌北クリニック
【 要旨 】 維持透析患者の高齢化が顕著となり,「認知症患者の透析開始」並びに「透析開始後の認知症発症」に関連する問題が深刻化している.認知症患者の終末期には,1) 認知症の重症化で不動・食事摂取不能などの結果と,2) 認知症の程度に変化はないが,腎不全に随伴した身体状態悪化の結果の2 種類が考えられる.いずれの状態であっても透析の施行が不可能か著しく困難・危険を伴うのであれば,日本透析医学会の「透析の見合わせ」提言に沿った意思決定が進められるべきである.一方,透析の施行が可能であっても認知症が重度に陥った場合には,患者自身の意向を強く忖度できる材料(事前指示や家族などの会話など)が存在すれば,それらを最大限尊重した家族や医療者による代理判断が必要であり容認されよう.患者の意向をまったく推測しえない場合には,家族・関係者などを中心に当該患者への最善策が模索されることになる.
Theme Cognitive impairment and dialysis therapy
Title End of life support for dementia patients receiving dialysis therapy
Author Seiji Ohira Sapporo Kita Clinic
[ Summary ] The aging of the maintenance dialysis patient population has become quite evident and problems related to initiating dialysis for dementia patients as well as the onset of dementia after initiating dialysis have become very serious. There are believed to be two common conditions in the terminal stage of dementia patients ; (1) dementia worsens resulting in immobility or loss of the ability to eat or, (2) there is no change in the severity of dementia yet their physical condition worsens brought about by renal failure. Whatever the patien's condition is, if it becomes impossible to perform dialysis or it is clearly difficult or dangerous, decision making should be carried out following the "Dialysis Withdrawal" proposal of the Japanese Society for Dialysis Therapy. On the other hand, even if dialysis can be performed, in cases involving severe dementia, can measures be taken to clearly determine the patient's intentions such as an advanced directive or conversations with family, surrogate decisions by the family or medical staff respecting this information to the fullest are necessary and should be allowed. In the event of the patient's intentions being completely unknown, the best possible plan is for the patient's desires to be determined by the family members or other concerned persons.
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