Patient-nephrologist prognostic awareness and discordance in end stage renal disease on renal replacement therapy

Perceived Life Expectancy Among Dialysis Recipients: A Scoping Review

Rationale & Objective

Greater prognostic understanding is associated with higher quality care at the end of life. We undertook a scoping review to explore how long dialysis recipients expect to live.

Study Design

Scoping Review.

Setting & Study Populations

People with kidney failure over 18 years old.

Search Strategy & Sources

Studies were identified by searching Medline, Embase, APA PsycINFO, HMIC, and ProQuest database for terms related to "life expectancy", "self-estimated", and "end stage kidney disease".

Data Extraction

Search strategies reported 349 unique, potentially eligible studies, with 8 studies meeting the inclusion criteria after screening.

Results

Significant mismatches between dialysis recipients and their health care provider's estimations of prognosis were reported, with patients predicting significantly higher life expectancies than health care professionals and almost no agreement between patient and nephrologist's estimates of 1-year survival. Documented cognitive impairment did not affect 1-year or 5-year prognosis estimates, nor did gender, age, time on dialysis, or discussing perceived life expectancy. Dialysis recipients who thought they were on the transplant list or who self-identified as African American reported higher perceived life expectancy, whereas people who were 75 years or older, or with fair or poor self-reported health status reported a lower perceived life expectancy. Those with a lower perceived life expectancy preferred care focusing on relieving pain and discomfort, whereas people who thought they had a higher chance of survival were significantly more likely to prefer life-extending care.

Limitations

There is a marked paucity of research in this area, with most studies conducted in North American cohorts.

Conclusions

Optimistic patient prognostic expectations persist in dialysis recipients. Given the effects of perceived life expectancy on treatment choices and subsequent quality of life, it is important that transparent discussions regarding prognosis are conducted with people receiving dialysis and their families.

Plain-Language Summary

Understanding illness severity and prognosis allows people to make decisions and prioritize areas of their lives that are important to them. We undertook a scoping review to explore how long dialysis recipients expect to live. We found significant mismatches between the perceived life expectancy of people treated with dialysis and their health care providers. Perceived life expectancy influenced treatment choices; thus, those who thought they would die sooner prioritized care focusing on relieving pain and discomfort. Those who thought they had a higher chance of survival were more likely to prefer life-extending care (with potential effects on quality of life). It is important to have frank discussions about prognosis with people receiving dialysis, to empower individuals and help them make informed decisions about their care.

Creating KidneyPal: A Specialty-Aligned Palliative Care Service for People with Kidney Disease

BACKGROUND

Patients with kidney disease have notable unmet palliative care needs and represent an underserved population for specialty palliative care teams.

INTERVENTION

We designed a specialty-aligned interprofessional palliative care service called KidneyPal that is aimed at improving delivery of palliative care to patients with kidney disease through focus groups and iterative improvement cycles.

MEASURES

We iteratively measured the development of KidneyPal through clinical process metrics: percent of the inpatient nephrology census followed by KidneyPal, patient demographics, consult origin, clinician feedback, and self-reported team interventions.

OUTCOMES

KidneyPal saw 314 unique patients from January 2019 to January 2021. The majority of consultations came from nephrology services though the source of consultation changed over time. We consulted on an average of 13.5% of the entire inpatient nephrology patient hospital census with highest involvement with patients on the inpatient nephrology hemodialysis service (mean of 29.9%). KidneyPal was rated highly by surveyed nephrology clinicians and provided high rates of psychosocial support and goals of care interventions.

LESSONS LEARNED

The creation of KidneyPal led to us to serve a new cohort of patients with specialty palliative care. We grew over time to serve the full range of patients with kidney disease as defined by our nephrology service lines. We succeeded in doing so by embedding in nephrology and building relationships with those caring for people with kidney disease while tailoring our service and interventions over time.