醫病共享決策對於慢性腎臟病人選擇腎臟病替代療法之成效及其影響因素

The Effects of Shared Decision Making on Selection of Renal Replacement Therapy in Patients with Chronic Kidney Disease and Related Factors

目的：當慢性腎臟病的病人在面臨腎臟替代療法的選擇時，希望能藉由『醫病共享決策shared decision making|SDM』來幫助病人在充分了解的狀況下，作出最適當的決策。流程：本科於105年成立SDM小組並發展輔助工具及評估表，由醫師轉介慢性腎臟病第五期病人予慢性腎臟病衛教師或透析治療師進行SDM。結果：106年1月至107年4月共115位病人，男性59人(51.3％)|平均年齡60.7±15.2歲。經SDM後病人對未來腎臟病替代療法之選擇為血液透析52人(45.2％)、腹膜透析41人(35.7％)、腎臟移植7人(6.1％)、安寧緩和9人(7.8％)、未能當下做決定6人(5.2％)，分析顯示不同年齡層的病人在選擇腎臟替代療法時會有差異。追蹤至107年4月進入透析共80人分別為血液透析53人(66.2％)、腹膜透析27人(33.8％)，未有腎臟移植及安寧緩和。將已進入透析之病人與先前作SDM時的選擇再次分析，前後選擇一致者分別為血液透析有16人(30.2％)、腹膜透析為6人(22.2％)。結論:透析治療仍是大多數慢性腎臟病病人的選擇，在心理層面中會影響病人做選擇的因素以病人的意願、自我照顧能力及生活品質為重要的考量。

Renal replacement therapy (RRT) is indicated when patients with chronic kidney disease (CKD) progress to uremia.With the introduction of shared decision making (SDM), patients can select the most appropriate therapy for their renal failure. A SDM coaching program was established in 2016 in our department. Patients with CKD stage 5 were referred to CKD case manager or dialysis therapists for SDM. During the period from January 2017 to April 2018, a total of 115 patients (male: 51.3%) were enrolled. Their mean age was 60.7± 15.2 years. Their decisions after SDM were: hemodialysis: fifty-two patients (45.2%), peritoneal dialysis: forty-one patients (35.7%), kidney transplantation: seven patients (6.1%), hospice care: nine patients (7.8%). six patients (5.2%) cannot make their decision right away after SDM. We found more patients younger than 55 years selecting peritoneal dialysis and transplantation (p were on peritoneal dialysis. None of them selected hospice care or transplantation. Comparing with their decision after SDM, consistent decision for hemodialysis was 16 patients (30.2%) and 6 patients (22.2%) in peritoneal dialysis. We concluded that dialysis remained the most selected therapy. The self-care ability, life quality and independent selection were important determinants of SDM for RRT.