Journal of the American Society of Nephrology : JASN
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J. Am. Soc. Nephrol. · Nov 1995
Randomized Controlled Trial Multicenter Study Clinical TrialLife-sustaining treatment preferences of hemodialysis patients: implications for advance directives.
The purpose of this study was to describe the life-sustaining treatment preferences of dialysis patients and to compare the acceptability of two generic and a disease-specific advance directive (AD). Of 532 potentially eligible hemodialysis patients, 95 (17.9%) participated in the study. These patients completed two generic (the Centre for Bioethics Living Will and the Medical Directive) and one disease-specific (the Dialysis Living Will) AD in a randomized cross-over trial. ⋯ Health states and illness severity, far more than treatment descriptions, influence preferences. Dialysis patients should be offered a generic AD, and some generic AD are more acceptable than others. Only a minority of dialysis patients will complete any AD, but the completion of written AD forms is only one element in the process of advance care planning.
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Continuous hemofiltration (CH) is being used in increasing numbers of pediatric intensive care unit patients. Experience with 114 CH treatments in 98 critically ill children from March 1988 to March 1993 is presented in this study. Ages ranged from 1 day to 23 yr (mean +/- SE = 7.1 +/- 0.7 yr), and 54% of patients were male. ⋯ Survival to hospital discharge was better in patients who did not receive pressors (P < 0.005) and in patients treated with combined ultrafiltration and dialysis (CAVH-D, CVVH-D) compared with ultrafiltration alone (CAVH, CVVH) (P < 0.005), but was not notably affected by patient age, sex, use of anticoagulation, filter life span, blood pump-assisted versus spontaneous CH, or duration of therapy. Filter life span was not affected by use of anticoagulation, but was remarkably longer in patients with arteriovenous versus venovenous CH (P < 0.004). It was concluded that: (1) empirical anticoagulation of patients treated with CH is not necessary; (2) children with a minority of underlying diseases and those requiring pressor support at initiation of CH appear to have relatively poor survival rates despite the technically effective use of CH; and (3) the addition of countercurrent dialysis to routine CH may enhance patient survival to hospital discharge.