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    "textoCompleto" => "<p class="elsevierStylePara">In recent years&#44; due to having enacted the law that regulates carrying out living wills &#40;Spanish Law 7&#47;2002 of 12 December&#44; regarding <span class="elsevierStyleBold">living wills</span> in the health care system&#41;&#44; the legislation permitting effective implementation of rights supported by the law has been promulgated throughout Spain&#191;s autonomous communities&#46; Although later than in other western countries where this right has been exercised for years&#44; we feel that there is a need to make aware the general population and the patients with advanced chronic kidney disease &#40;ACKD&#41; in particular&#44; of this right&#44; since knowledge about living wills and how to make use of them is generally quite limited&#46; Knowledge of the law is also limited among health care professionals&#44; which is why we need to make an effort to publicise this information&#46;</p><p class="elsevierStylePara">A living will&#44; also known as <span class="elsevierStyleBold">advance directives</span>&#44; includes a set of documents in which the patient explains his&#47;her wishes for a life plan and end-of-life plan&#46; Living wills contain two fundamental components&#46; One is the <span class="elsevierStyleBold">advance statement</span>&#44; a document that reflects the individual&#191;s wishes regarding the care that he&#47;she would like to receive in the event of becoming incapacitated&#44; and provides care providers with specific instructions regarding different aspects of the end of his&#47;her life&#46; The second component is the <span class="elsevierStyleBold">choice of a representative</span> &#40;a proxy or PoA&#41;&#44; who will act in the name of the patient should he&#47;she become incapacitated&#46; This representative should have ample knowledge of the patient&#191;s wishes&#46;</p><p class="elsevierStylePara">In general&#44; doctors resist &#191;giving bad news&#191;&#44; meaning that in many cases&#44; doctor-patient communication is not adequate&#44; and the patient has only partial information about the true scope of his&#47;her disease&#46; It is important to establish a multidisciplinary approach in which doctors&#44; nurses&#44; bio-ethicists and social workers participate&#46; Involvement the family in this dialogue is fundamental&#46; It has been stated that the quality of family relationships determine whether or not there is a living will in many cases&#46;<span class="elsevierStyleSup">1</span> We must determine how much the patient knows and wishes to know&#46; If the patient does not want very much information&#44; we speak about treatment plans&#44; and if the patient does wish to know&#44; we provide information according to what is agreed&#46; We must respond to the patient&#191;s feelings and establish means of communication that will be important for planning a future strategy&#46; The patient and the family should participate in this process&#44; but we must always remember that the patient&#191;s feelings and wishes are the most important&#46;</p><p class="elsevierStylePara">The doctor&#191;s responsibility in the decision process will vary according to the patient&#191;s level of competence&#46; If the patient is mentally competent&#44; the decision will always be his or hers&#46; If the patient is mentally incapacitated&#44; this will depend on whether or not he&#47;she has made wishes known through a living will or the designation of a representative&#46; If there is no will or representative&#44; the decision must be made by the doctor and the family together&#46; This is the most common situation at present&#46;<span class="elsevierStyleBold"></span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">LIVING WILLS AND ACKD</span></p><p class="elsevierStylePara">Currently&#44; developed countries place no limits on the use of renal replacement therapy &#40;RRT&#41;&#46; As a result the suitability of treatment in each individual patient is often not evaluated properly&#44; although it is known that not all patients benefit equally from RRT&#46; The excessive number of patients on RRT in countries such as the United States has been attributed to issues such as patients having limited knowledge of their disease&#44; poor communication between the patient&#44; the family and the doctor and the fact that there is no policy for restricting treatment&#46; Whether or not there are available slots in the dialysis unit often influences the decision&#46;</p><p class="elsevierStylePara">On the other hand&#44; despite the high mortality rate of patients with ACKD&#44; these patients do not see themselves as having a terminal illness and think that they can stay alive on dialysis indefinitely&#46; Many patients do not consider expressing their end-of-life wishes until it is late and they have lost a large part of their cognitive function&#46; In the USA&#44; only 30&#37; of patients on dialysis have a living will or have discussed or expressed their position regarding dialysis&#44; and of these&#44; 66&#37; do not know the role of a representative&#44; 42&#37; do not know what legal status their living will has&#44; 77&#37; have discussed their wishes with the family or a close friend&#44; only 17&#37; have discussed their wishes with their doctor&#44; and 51&#37; think that living wills could influence the doctor&#191;s attitude toward their treatment&#46; One aspect that highlights the lack of awareness about the seriousness of the disease is the fact that the position regarding discontinuing dialysis is not usually expressed in living wills&#46;<span class="elsevierStyleSup">3</span></p><p class="elsevierStylePara">The existence of a living will can be very important in some patient groups&#44; such as those who are incapacitated and for whom starting or discontinuing dialysis is being evaluated&#59; the patients with prolonged impaired consciousness&#59; patients with severe&#44; irreversible dementia or severe mental deterioration&#59; patients incapable of cooperating with the dialysis procedure or communicating with the doctor and patients with a low life expectancy &#40;&#60; 60 days&#41; due to terminal illness or end-stage lung&#44; liver or heart disease who are bed-ridden and who need assistance for daily life activities&#46;<span class="elsevierStyleSup">4</span></p><p class="elsevierStylePara">However&#44; despite their insufficient knowledge of living wills&#44; when patients are asked what they want in hypothetical situations&#44; their opinions are quite clear&#46; In a questionnaire given to 532 patients who were potentially eligible for dialysis&#44; 86&#37; of patients stated that they wanted to undergo dialysis in their current state of health&#59; 84&#37; would want it in the event of a mild stroke&#44; 60&#37; after a moderate stroke and 21&#37; after a severe stroke&#59; 41&#37; in the event of having a terminal illness&#44; 14&#37; in severe dementia and 10&#37; in the event of a permanent coma&#46;<span class="elsevierStyleSup">5</span></p><p class="elsevierStylePara">Planned arrival at the dialysis stage makes decision-making easier by allowing the patient to receive information on the illness and treatment options during pre-dialysis appointments&#44; and in this case&#44; he or she has the opportunity to decide on the conditions and level of acceptance for that treatment&#46; Lack of planning implies conditioning and diminishing the freedom of choice&#46;<span class="elsevierStyleBold"></span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">ADVANCE CARE PLANNING FOR ACKD</span></p><p class="elsevierStylePara">For all patients starting RRT&#44; nephrologists should recommend and obtain a living will&#44; since these documents serve as an excellent tool for future medical care and decision-making&#46;</p><p class="elsevierStylePara">Discussions about end of life tend to be late for patients on dialysis&#44; and with time&#44; cognitive function decreases&#46; This matter should be broached early in order to be able to respect the patient&#191;s autonomy and values&#46; It is necessary to consider the patient&#191;s feelings through in-depth dialogue&#44; and plan his&#47;her future care in its entirely taking into account ethical and psycho-social aspects and any other issues related to starting&#44; continuing&#44; maintaining and discontinuing dialysis treatment&#46;<span class="elsevierStyleSup">6</span> The planning process should be carried out at the time when the patient is given education and information on dialysis options&#46; This process should be complementary to the consent process for choosing dialysis options&#44; except perhaps in patients with low comorbidity or who will be receiving transplants in the near future&#46;<span class="elsevierStyleSup">7</span></p><p class="elsevierStylePara">The clinical approach to the decision-making process implies evaluating the patient&#191;s decision-making capacity and whether the patient is aware of his&#47;her situation and the consequences of the decision&#44; and if he&#47;she has informed loved ones and the medical staff about the decision&#46; The doctor must check whether or not a living will exists&#44; particularly for incapacitated patients who have previously expressed in writing that they do not want to be on life support&#44; or those who do not have a living will but who have clearly stated that they do not want dialysis&#44; and verify whether there is a representative or not&#46;</p><p class="elsevierStylePara">Likewise&#44; it is necessary to evaluate potentially reversible factors&#44; and the nephrologist should rule out the existence of depression&#44; dementia&#44; or uraemic or toxic encephalopathy that might condition a patient&#191;s decision&#46;</p><p class="elsevierStylePara">On some occasions&#44; or if the patient is having doubts&#44; you might agree on a &#191;trial period&#191;&#59; some patients with terminal illness &#40;metastasised cancer&#41; might need &#191;temporary dialysis&#191; in order to resolve personal and social problems before their foreseen death&#46; Involvement by the team and the family is fundamental&#46; The majority of patients prefer to discuss these decisions with their families rather than with their doctors &#40;50 vs&#46; 6&#37;&#41;&#46;<span class="elsevierStyleSup">8</span> If the patient clearly refuses dialysis&#44; post-decision palliative care measures that contribute to the dignity of the death should be planned&#46;9 Documentation plays an important role&#44; given that the patient&#191;s preferences should be clearly reflected in the clinical history&#44; should accompany the patient&#44; and must be known by all who are involved in the decision process&#46;<span class="elsevierStyleBold"></span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">DIFFERING SITUATIONS FOR PATIENTS WITH ACKD</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conservative treatment&#58; patient refuses to go on dialysis</span></p><p class="elsevierStylePara">It is important to follow a proper decision-making process&#44; since patients should understand what their decision means and provide a life plan and state how the end of life should be managed in writing&#46; It is necessary for the patient&#191;s care providers to understand the patient&#191;s needs and be supportive of their decisions&#44; and arbitrate the means for palliative care of the patient&#46;<span class="elsevierStyleSup">9&#44;10</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conservative treatment&#58; patient not indicated for dialysis</span></p><p class="elsevierStylePara">This is a very frequent situation in clinical practice&#46; It is possibly more frequent than discontinuing dialysis&#44; and is the case of 25&#37; of all patients referred for dialysis in Canada&#46;<span class="elsevierStyleSup">11</span> Many patients who are seen in a primary care centre are not referred to Nephrology because they are not considered candidates for dialysis&#44; due to being incapacitated by serious dementia&#44; being unconscious&#44; or having a severe mental disability&#46; Other patients&#44; however&#44; who are competent &#40;those with terminal illnesses and intense&#44; continuous pain&#41; and have the ability to make decisions should therefore be included in the living will protocol&#46; We cannot overlook the fact that all people have the ethical and legal right to refuse treatment after receiving adequate information regarding the nature of the disease&#44; and all aspects of treatment&#44; and who are aware of the consequences of their decisions&#46; We must stress that for competent patients&#44; the decision to accept or reject treatment legally belongs to the patient&#44; and not to the doctor&#46;<span class="elsevierStyleBold"></span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Treatment trial period</span></p><p class="elsevierStylePara">This situation occurs in patients with high comorbidity&#46; For these patients&#44; the nephrologist can propose dialysis during a trial period to attempt to improve the patient&#191;s quality of life&#44; and discontinue dialysis if there is no improvement&#46; This situation requires a high level of doctor-patient communication&#44; and the treatment must be re-evaluated at the pre-established time&#46;<span class="elsevierStyleBold"></span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Advantages of advance care planning</span></p><p class="elsevierStylePara">Exercising this right has advantages for all involved&#46; The advantages for patients include enabling them to take charge of self-determination helping them to die with dignity and permitting them to choose a trusted representative for making important decisions&#46; It also has advantages for the family&#44; who are greatly aided by having discussed and defined the patient&#191;s position before the end of life and are relieved of part of their responsibility for making difficult decisions&#59; in addition&#44; it clarifies dialogue with the health care professional&#46; Thirdly&#44; there are advantages for the health care personnel&#44; because it makes decision-making simpler&#44; ensures that the patient&#191;s wishes are respected regarding his&#47;her life and end-of-life plan&#44; and improves dialogue with the family&#46;</p><p class="elsevierStylePara">To sum up&#44; nephrologists involved in treating patients with ACKD have to face the challenge of developing this right which&#44; although recognised by law&#44; is infrequently exercised due to being largely unknown by patients and health care professionals&#46; Nephrologists should assume an active role in recognising this right&#46; This is a challenge&#44; but if we meet it&#44; we will increase our patients&#191; 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Advance care planning before starting dialysis
Planificación anticipada e inicio de diálisis
Grupo de Ética y Nefrología de la S.E.N., José Antonio Sánchez Tomerob
b Servicio de Nefrología, Hospital Universitario de la Princesa, Madrid, Madrid, España,
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    "textoCompleto" => "<p class="elsevierStylePara">In recent years&#44; due to having enacted the law that regulates carrying out living wills &#40;Spanish Law 7&#47;2002 of 12 December&#44; regarding <span class="elsevierStyleBold">living wills</span> in the health care system&#41;&#44; the legislation permitting effective implementation of rights supported by the law has been promulgated throughout Spain&#191;s autonomous communities&#46; Although later than in other western countries where this right has been exercised for years&#44; we feel that there is a need to make aware the general population and the patients with advanced chronic kidney disease &#40;ACKD&#41; in particular&#44; of this right&#44; since knowledge about living wills and how to make use of them is generally quite limited&#46; Knowledge of the law is also limited among health care professionals&#44; which is why we need to make an effort to publicise this information&#46;</p><p class="elsevierStylePara">A living will&#44; also known as <span class="elsevierStyleBold">advance directives</span>&#44; includes a set of documents in which the patient explains his&#47;her wishes for a life plan and end-of-life plan&#46; Living wills contain two fundamental components&#46; One is the <span class="elsevierStyleBold">advance statement</span>&#44; a document that reflects the individual&#191;s wishes regarding the care that he&#47;she would like to receive in the event of becoming incapacitated&#44; and provides care providers with specific instructions regarding different aspects of the end of his&#47;her life&#46; The second component is the <span class="elsevierStyleBold">choice of a representative</span> &#40;a proxy or PoA&#41;&#44; who will act in the name of the patient should he&#47;she become incapacitated&#46; This representative should have ample knowledge of the patient&#191;s wishes&#46;</p><p class="elsevierStylePara">In general&#44; doctors resist &#191;giving bad news&#191;&#44; meaning that in many cases&#44; doctor-patient communication is not adequate&#44; and the patient has only partial information about the true scope of his&#47;her disease&#46; It is important to establish a multidisciplinary approach in which doctors&#44; nurses&#44; bio-ethicists and social workers participate&#46; Involvement the family in this dialogue is fundamental&#46; It has been stated that the quality of family relationships determine whether or not there is a living will in many cases&#46;<span class="elsevierStyleSup">1</span> We must determine how much the patient knows and wishes to know&#46; If the patient does not want very much information&#44; we speak about treatment plans&#44; and if the patient does wish to know&#44; we provide information according to what is agreed&#46; We must respond to the patient&#191;s feelings and establish means of communication that will be important for planning a future strategy&#46; The patient and the family should participate in this process&#44; but we must always remember that the patient&#191;s feelings and wishes are the most important&#46;</p><p class="elsevierStylePara">The doctor&#191;s responsibility in the decision process will vary according to the patient&#191;s level of competence&#46; If the patient is mentally competent&#44; the decision will always be his or hers&#46; If the patient is mentally incapacitated&#44; this will depend on whether or not he&#47;she has made wishes known through a living will or the designation of a representative&#46; If there is no will or representative&#44; the decision must be made by the doctor and the family together&#46; This is the most common situation at present&#46;<span class="elsevierStyleBold"></span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">LIVING WILLS AND ACKD</span></p><p class="elsevierStylePara">Currently&#44; developed countries place no limits on the use of renal replacement therapy &#40;RRT&#41;&#46; As a result the suitability of treatment in each individual patient is often not evaluated properly&#44; although it is known that not all patients benefit equally from RRT&#46; The excessive number of patients on RRT in countries such as the United States has been attributed to issues such as patients having limited knowledge of their disease&#44; poor communication between the patient&#44; the family and the doctor and the fact that there is no policy for restricting treatment&#46; Whether or not there are available slots in the dialysis unit often influences the decision&#46;</p><p class="elsevierStylePara">On the other hand&#44; despite the high mortality rate of patients with ACKD&#44; these patients do not see themselves as having a terminal illness and think that they can stay alive on dialysis indefinitely&#46; Many patients do not consider expressing their end-of-life wishes until it is late and they have lost a large part of their cognitive function&#46; In the USA&#44; only 30&#37; of patients on dialysis have a living will or have discussed or expressed their position regarding dialysis&#44; and of these&#44; 66&#37; do not know the role of a representative&#44; 42&#37; do not know what legal status their living will has&#44; 77&#37; have discussed their wishes with the family or a close friend&#44; only 17&#37; have discussed their wishes with their doctor&#44; and 51&#37; think that living wills could influence the doctor&#191;s attitude toward their treatment&#46; One aspect that highlights the lack of awareness about the seriousness of the disease is the fact that the position regarding discontinuing dialysis is not usually expressed in living wills&#46;<span class="elsevierStyleSup">3</span></p><p class="elsevierStylePara">The existence of a living will can be very important in some patient groups&#44; such as those who are incapacitated and for whom starting or discontinuing dialysis is being evaluated&#59; the patients with prolonged impaired consciousness&#59; patients with severe&#44; irreversible dementia or severe mental deterioration&#59; patients incapable of cooperating with the dialysis procedure or communicating with the doctor and patients with a low life expectancy &#40;&#60; 60 days&#41; due to terminal illness or end-stage lung&#44; liver or heart disease who are bed-ridden and who need assistance for daily life activities&#46;<span class="elsevierStyleSup">4</span></p><p class="elsevierStylePara">However&#44; despite their insufficient knowledge of living wills&#44; when patients are asked what they want in hypothetical situations&#44; their opinions are quite clear&#46; In a questionnaire given to 532 patients who were potentially eligible for dialysis&#44; 86&#37; of patients stated that they wanted to undergo dialysis in their current state of health&#59; 84&#37; would want it in the event of a mild stroke&#44; 60&#37; after a moderate stroke and 21&#37; after a severe stroke&#59; 41&#37; in the event of having a terminal illness&#44; 14&#37; in severe dementia and 10&#37; in the event of a permanent coma&#46;<span class="elsevierStyleSup">5</span></p><p class="elsevierStylePara">Planned arrival at the dialysis stage makes decision-making easier by allowing the patient to receive information on the illness and treatment options during pre-dialysis appointments&#44; and in this case&#44; he or she has the opportunity to decide on the conditions and level of acceptance for that treatment&#46; Lack of planning implies conditioning and diminishing the freedom of choice&#46;<span class="elsevierStyleBold"></span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">ADVANCE CARE PLANNING FOR ACKD</span></p><p class="elsevierStylePara">For all patients starting RRT&#44; nephrologists should recommend and obtain a living will&#44; since these documents serve as an excellent tool for future medical care and decision-making&#46;</p><p class="elsevierStylePara">Discussions about end of life tend to be late for patients on dialysis&#44; and with time&#44; cognitive function decreases&#46; This matter should be broached early in order to be able to respect the patient&#191;s autonomy and values&#46; It is necessary to consider the patient&#191;s feelings through in-depth dialogue&#44; and plan his&#47;her future care in its entirely taking into account ethical and psycho-social aspects and any other issues related to starting&#44; continuing&#44; maintaining and discontinuing dialysis treatment&#46;<span class="elsevierStyleSup">6</span> The planning process should be carried out at the time when the patient is given education and information on dialysis options&#46; This process should be complementary to the consent process for choosing dialysis options&#44; except perhaps in patients with low comorbidity or who will be receiving transplants in the near future&#46;<span class="elsevierStyleSup">7</span></p><p class="elsevierStylePara">The clinical approach to the decision-making process implies evaluating the patient&#191;s decision-making capacity and whether the patient is aware of his&#47;her situation and the consequences of the decision&#44; and if he&#47;she has informed loved ones and the medical staff about the decision&#46; The doctor must check whether or not a living will exists&#44; particularly for incapacitated patients who have previously expressed in writing that they do not want to be on life support&#44; or those who do not have a living will but who have clearly stated that they do not want dialysis&#44; and verify whether there is a representative or not&#46;</p><p class="elsevierStylePara">Likewise&#44; it is necessary to evaluate potentially reversible factors&#44; and the nephrologist should rule out the existence of depression&#44; dementia&#44; or uraemic or toxic encephalopathy that might condition a patient&#191;s decision&#46;</p><p class="elsevierStylePara">On some occasions&#44; or if the patient is having doubts&#44; you might agree on a &#191;trial period&#191;&#59; some patients with terminal illness &#40;metastasised cancer&#41; might need &#191;temporary dialysis&#191; in order to resolve personal and social problems before their foreseen death&#46; Involvement by the team and the family is fundamental&#46; The majority of patients prefer to discuss these decisions with their families rather than with their doctors &#40;50 vs&#46; 6&#37;&#41;&#46;<span class="elsevierStyleSup">8</span> If the patient clearly refuses dialysis&#44; post-decision palliative care measures that contribute to the dignity of the death should be planned&#46;9 Documentation plays an important role&#44; given that the patient&#191;s preferences should be clearly reflected in the clinical history&#44; should accompany the patient&#44; and must be known by all who are involved in the decision process&#46;<span class="elsevierStyleBold"></span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">DIFFERING SITUATIONS FOR PATIENTS WITH ACKD</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conservative treatment&#58; patient refuses to go on dialysis</span></p><p class="elsevierStylePara">It is important to follow a proper decision-making process&#44; since patients should understand what their decision means and provide a life plan and state how the end of life should be managed in writing&#46; It is necessary for the patient&#191;s care providers to understand the patient&#191;s needs and be supportive of their decisions&#44; and arbitrate the means for palliative care of the patient&#46;<span class="elsevierStyleSup">9&#44;10</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conservative treatment&#58; patient not indicated for dialysis</span></p><p class="elsevierStylePara">This is a very frequent situation in clinical practice&#46; It is possibly more frequent than discontinuing dialysis&#44; and is the case of 25&#37; of all patients referred for dialysis in Canada&#46;<span class="elsevierStyleSup">11</span> Many patients who are seen in a primary care centre are not referred to Nephrology because they are not considered candidates for dialysis&#44; due to being incapacitated by serious dementia&#44; being unconscious&#44; or having a severe mental disability&#46; Other patients&#44; however&#44; who are competent &#40;those with terminal illnesses and intense&#44; continuous pain&#41; and have the ability to make decisions should therefore be included in the living will protocol&#46; We cannot overlook the fact that all people have the ethical and legal right to refuse treatment after receiving adequate information regarding the nature of the disease&#44; and all aspects of treatment&#44; and who are aware of the consequences of their decisions&#46; We must stress that for competent patients&#44; the decision to accept or reject treatment legally belongs to the patient&#44; and not to the doctor&#46;<span class="elsevierStyleBold"></span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Treatment trial period</span></p><p class="elsevierStylePara">This situation occurs in patients with high comorbidity&#46; For these patients&#44; the nephrologist can propose dialysis during a trial period to attempt to improve the patient&#191;s quality of life&#44; and discontinue dialysis if there is no improvement&#46; This situation requires a high level of doctor-patient communication&#44; and the treatment must be re-evaluated at the pre-established time&#46;<span class="elsevierStyleBold"></span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Advantages of advance care planning</span></p><p class="elsevierStylePara">Exercising this right has advantages for all involved&#46; The advantages for patients include enabling them to take charge of self-determination helping them to die with dignity and permitting them to choose a trusted representative for making important decisions&#46; It also has advantages for the family&#44; who are greatly aided by having discussed and defined the patient&#191;s position before the end of life and are relieved of part of their responsibility for making difficult decisions&#59; in addition&#44; it clarifies dialogue with the health care professional&#46; Thirdly&#44; there are advantages for the health care personnel&#44; because it makes decision-making simpler&#44; ensures that the patient&#191;s wishes are respected regarding his&#47;her life and end-of-life plan&#44; and improves dialogue with the family&#46;</p><p class="elsevierStylePara">To sum up&#44; nephrologists involved in treating patients with ACKD have to face the challenge of developing this right which&#44; although recognised by law&#44; is infrequently exercised due to being largely unknown by patients and health care professionals&#46; Nephrologists should assume an active role in recognising this right&#46; This is a challenge&#44; but if we meet it&#44; we will increase our patients&#191; autonomy and magnify their ability to choose&#46; We must develop protocols for advance care planning&#44; improve the training and involvement of health care personnel and develop information systems to enable the practical application of patients&#191; advance decisions&#46; <br></br></p>"
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