| Summary: | 碩士 === 國立臺灣大學 === 醫療機構管理研究所 === 98 === Background: The increasing prevalence of end stage renal failure patients is challenging in health care system around the world. In addition to prevention of the dialysis initiation, it is important in dialysis withdrawal if proven futile. Few data is available about factors associated with proposal of dialysis withdrawal for critically-ill ESRD patients. We therefore studied physician’s views and factors influencing physician’s decision-making on dialysis withdrwal.
Methods: We surveyed 275 physicians who were experienced in care of ESRD patients about their views on dialysis withdrawal. One hypothetical case with five clinical scenarios was included. Participants score their responses according Likert scale as a report to agree/disagree with the 10 statement within each scenarios. Participants’ demographic data were recorded. The correlation of demographic data to agreement of each scenario was calculated with chi-square test. The association of agreement to each statement was calculated with logistic regression method. It is statistically significant when p<0.05.
Results : Of 275 physicians, 249 completed surveys and 240 effectively returned . Fourteen percent of physicians agreed to withdraw dialysis in scenario one when clinical information of the hypothetical ESRD patient with old age and dementia. Highest agreement ( 86.4%) was achieved in scenario three when families responded agreement to dialysis withdrawal. There are different demographic factors associated with dialysis withdrawal proposal in each scenario are hospital at northern Taiwan (scenario 1,4)、level of training(Scenario 3,4)、subspecialty(scenario 3)、ICU full-time physician(scenario 4)、experience of proposal of dialysis withdrawal in the preceeding year(scenario 3-5) and gender (scenario 5). Logistic regression result showed physician experts ( his/her own opinion) possessed the most important consideration (odds ratio: 2.908, 2.617, 2.970, 2.809, p<0.01) associated with dialysis withdrawal proposal in four scenario (scenario 1,2,3,5). Age factor also affected dialysis withdrawal decision-making (odds ratio: 2.294, 2.085, 3.200, 1.862, p<0.01) in four scenario( scenario 1-4). The significance of associated factors in dialysis withdrawal was modified in different extents after adjusted with demographic background. It represents that the decision-making in dialysis withdrawal is a dynamic process, which is influenced by physician’s personal characteristics.
Conclusion: Physicians exert different thinking process according to different clinical scenarios. Our study identified factors associated with dialysis withdrawal decision-making process. Further education program will be indicated for junior doctors about timing and consideration in dialysis withdrawal to achieve optimal end-of-life care in critically-ill ESRD patietns.
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