Letter to the Editor
Shared decision-making in advanced chronic kidney disease in the elderly. Follow the example
Toma de decisiones compartida en la enfermedad renal crónica avanzada del anciano. Un ejemplo a seguir
Isabel Torrente Jiménez
, Susana Herranz Martínez, Marc Moreno Ariño
Corresponding author
Unidad de Geriatría de Agudos y Paciente Crónico Complejo, Consorci Sanitari Parc Taulí, Sabadell, Barcelona, Spain
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Follow the example" "tieneTextoCompleto" => true "saludo" => "Dear Editor:" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "32" "paginaFinal" => "33" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Isabel Torrente Jiménez, Susana Herranz Martínez, Marc Moreno Ariño" "autores" => array:3 [ 0 => array:4 [ "nombre" => "Isabel" "apellidos" => "Torrente Jiménez" "email" => array:1 [ 0 => "isaluna29@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Susana" "apellidos" => "Herranz Martínez" ] 2 => array:2 [ "nombre" => "Marc" "apellidos" => "Moreno Ariño" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Unidad de Geriatría de Agudos y Paciente Crónico Complejo, Consorci Sanitari Parc Taulí, Sabadell, Barcelona, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Toma de decisiones compartida en la enfermedad renal crónica avanzada del anciano. Un ejemplo a seguir" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1243 "Ancho" => 2500 "Tamanyo" => 245307 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Multidisciplinary management for decision-making in elderly patients with advanced chronic kidney disease.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We read with interest the review by Heras Benito et al.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> on shared decision-making in advanced chronic kidney disease (CKD) in the elderly. As they comment in their article, we face a public health challenge derived from the ageing of the population, accompanied by comorbidity, fragility and other geriatric syndromes. This situation makes acquiring the relevant skills in these areas increasingly necessary. Giving a prognosis of chronic diseases and addressing shared decision-making is a challenge for all healthcare professionals, and it requires abandoning paternalistic and diagnostic-centred medicine in favour of a needs-centred model.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> In this regard, we wish to give our reflections on the fact that the approach proposed for elderly patients with CKD should be an example and a model for all medical specialties that, in general, deal with patients who will die after having lived with organ failure for years.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Regarding comorbidity, it should be noted that elderly patients with CKD are usually not only comorbid but also pluripatological and therefore the PROFUND<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> index would be a better tool when assessing prognosis, compared to the classic Charlson index and its already known limitations</p><p id="par0015" class="elsevierStylePara elsevierViewall">As mentioned, the clinical and functional heterogeneity of the elderly patient means that ageing in health is better contemplated in terms of fragility and not in years of life. Therefore, we consider the evaluation of fragility and functional status to be highly relevant, as they are elements that will play a fundamental role in patients’ situational diagnosis and prognosis. Regarding the assessment of fragility, a brief explanation is made and the two models of fragility are considered as two options to choose from. We believe that we they are compatible and not opposed. Fried's physical fragility model will give us a categorical result that helps us identify a fragile or at-risk elderly patient. From here we can use the different measurement tools from the Rockwood multidimensional fragility model.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The choice of each instrument will depend on the means available and the clinical scenario, while always bearing in mind that the gold standard is the comprehensive geriatric assessment. This multi-domain evaluation will provide us with elements of judgement to establish a proportionate strategy that rejects nihilism and therapeutic aggressiveness and moves us closer to the objective of improving quality of life.</p><p id="par0020" class="elsevierStylePara elsevierViewall">As mentioned, CKD is characterised by a chronic deterioration of months or years, whose trajectory can be modified with the appearance of other disease trajectories. It is worth noting that whatever the final trajectory is, offering advance planning is a process that adds value and addressing it from its initial stages of the RFQ can favour shared decision making on the most appropriate treatment, future actions for foreseeable complications, difficult management situations such as acute dialysis, ensuring caregivers are involved and dealing with issues that concern a more advanced disease, such as the future withdrawal from dialysis.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Referring to the section on palliative care in CKD, it is said that early care should begin as soon as the answer to the following question is ‘no’: “Would you be surprised if this patient died within 6–12 months?”. We wish to point out that patients who meet this criterion are candidates to receive care focused on their needs, but are not the only ones. Since we are talking about an elderly patient with a chronic disease in which palliative needs appear gradually, it would seem more appropriate to address palliative care needs progressively from the moment CKD is diagnosed.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> In this way we move from talking about palliative care to palliative primary care, with a broader vision in which we assume that the specific treatment does not contraindicate the palliative treatment given and we favour a more autonomous role for the patient who participates in making shared decisions.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Finally, regarding the multidisciplinary approach that is proposed, we believe including the primary care team is essential, as it will undoubtedly facilitate the transition of care when the patient no longer requires hospital care (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Torrente Jiménez I, Herranz Martínez S, Moreno Ariño M. Toma de decisiones compartida en la enfermedad renal crónica avanzada del anciano. Un ejemplo a seguir. Med Clin (Barc). 2020;154:32–33.</p>" ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1243 "Ancho" => 2500 "Tamanyo" => 245307 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Multidisciplinary management for decision-making in elderly patients with advanced chronic kidney disease.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Toma de decisiones compartida en la enfermedad renal crónica avanzada del anciano" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "M. 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Rockwood" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/S0140-6736(12)62167-9" "Revista" => array:6 [ "tituloSerie" => "Lancet" "fecha" => "2013" "volumen" => "381" "paginaInicial" => "752" "paginaFinal" => "762" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23395245" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The intersection between geriatrics and palliative care: A call for a new research agenda" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "N.E. Goldstein" 1 => "R.S. Morrison" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1532-5415.2005.53454.x" "Revista" => array:2 [ "tituloSerie" => "J Am Geriatr Soc" "fecha" => "2005" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23870206/0000015400000001/v2_202002131702/S2387020619305169/v2_202002131702/en/main.assets" "Apartado" => array:4 [ "identificador" => "43309" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23870206/0000015400000001/v2_202002131702/S2387020619305169/v2_202002131702/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020619305169?idApp=UINPBA00004N" ]
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