Quality end-of-life care in dialysis units

Unravelling complex choices: multi-stakeholder perceptions on dialysis withdrawal and end-of-life care in kidney disease

BACKGROUND

For patients on dialysis with poor quality of life and prognosis, dialysis withdrawal and subsequent transition to palliative care is recommended. This study aims to understand multi-stakeholder perspectives regarding dialysis withdrawal and identify their information needs and support for decision-making regarding withdrawing from dialysis and end-of-life care.

METHODS

Participants were recruited through purposive sampling from eight dialysis centers and two public hospitals in Singapore. Semi-structured in-depth interviews were conducted with 10 patients on dialysis, 8 family caregivers, and 16 renal healthcare providers. They were held in-person at dialysis clinics with patients and caregivers, and virtually via video-conferencing with healthcare providers. Interviews were audio-recorded, transcribed, and thematically analyzed. The Ottawa Decision Support Framework's decisional-needs manual was used as a guide for data collection and analysis, with two independent team members coding the data.

RESULTS

Four themes reflecting perceptions and support for decision-making were identified: a) poor knowledge and fatalistic perceptions; b) inadequate resources and support for decision-making; c) complexity of decision-making, unclear timing, and unpreparedness; and d) internal emotions of decisional conflict and regret. Participants displayed limited awareness of dialysis withdrawal and palliative care, often perceiving dialysis withdrawal as medical abandonment. Patient preferences regarding decision-making ranged from autonomous control to physician or family-delegated choices. Cultural factors contributed to hesitancy and reluctance to discuss end-of-life matters, resulting in a lack of conversations between patients and providers, as well as between patients and their caregivers.

CONCLUSIONS

Decision-making for dialysis withdrawal is complicated, exacerbated by a lack of awareness and conversations on end-of-life care among patients, caregivers, and providers. These findings emphasize the need for a culturally-sensitive tool that informs and prepares patients and their caregivers to navigate decisions about dialysis withdrawal and the transition to palliative care. Such a tool could bridge information gaps and stimulate meaningful conversations, fostering informed and culturally aligned decisions during this critical juncture of care.

Relationships of social support and attitudes towards death: A mediator role of depression in older patients on haemodialysis

AIM

To explore the mediating role of depression in older people receiving haemodialysis on social support and the attitude of participants towards death.

DESIGN

A cross-sectional questionnaire survey.

METHODS

Data were collected from older people undergoing dialysis (N = 209) at two regional hospitals in the north of Taiwan. Confirmatory factor analysis with structural equation model was used to clarify the strength of relationships and intermediary effects of three scales in which with 5,000 bootstrap samples using LISREL 9.31.

RESULTS

The final model provided a good fit for the data. Social support and depression have statistically significant effects on dialysis older person' negative death attitudes. The direct effect of social support on depression was the strongest (p<.001). Overall, depression completely mediates social support and positive death attitudes. Depression partially mediates social support and negative death attitude.

Opinions of hemodialysis and peritoneum patients regarding depression and psychological problems which they experience: A qualitative study

BACKGROUND

Dialysis are the treatment modalities that affect the quality of life. The objective of this qualitative study is to reveal how hemodialysis and peritoneal dialysis patients perceive depression and psychological problems which they experience.

METHODS

An interpretative phenomenological analysis approach, as espoused by Smith and Osborn provided the framework for this study. The study was performed in hemodialysis and peritoneal dialysis units of a university hospital. 10 adult hemodialysis patients and 10 adult peritoneal dialysis patients, selected. In-depth, semi-structured, face-to-face interviews were held with the patients. All interviews were digitally recorded and subjected to qualitative analysis after transcription.

RESULTS

Analysis revealed themes suggesting that hemodialysis and peritoneal dialysis patients frequently experienced depression as well as psychological problems such as decreased social support, burnout, despair, and anxiety.

CONCLUSIONS

It was concluded as a result of this study that the prolonged hemodialysis and peritoneal dialysis process negatively affected patients with chronic kidney disorders.

End-of-life care decisions for haemodialysis patients - 'We only tend to have that discussion with them when they start deteriorating'

BACKGROUND

Haemodialysis patients receive very little involvement in their end-of-life care decisions. Issues relating to death and dying are commonly avoided until late in their illness. This study aimed to explore the experiences and perceptions of doctors and nurses in nephrology for involving haemodialysis patients in end-of-life care decisions.

METHODS

A semi-structured qualitative interview study with 15 doctors and five nurses and thematic analysis of their accounts was conducted. The setting was a large teaching hospital in Wales, UK.

RESULTS

Prognosis is not routinely discussed with patients, in part due to a difficulty in estimation and the belief that patients do not want or need this information. Advance care planning is rarely carried out, and end-of-life care discussions are seldom initiated prior to patient deterioration. There is variability in end-of-life practices amongst nephrologists; some patients are felt to be withdrawn from dialysis too late. Furthermore, the possibility and implications of withdrawal are not commonly discussed with well patients. Critical barriers hindering better end-of-life care involvement for these patients are outlined.

CONCLUSIONS

The study provides insights into the complexity of end-of-life conversations and the barriers to achieving better end-of-life communication practices. The results identify opportunities for improving the lives and deaths of haemodialysis patients.

A comparison of the discursive practices of perception of patient participation in haemodialysis units

BACKGROUND

According to Norwegian law, nurses are obligated to provide an acceptable level of health assistance to patients and their family members and to allow patients and their family members to participate in the planning of patient care and treatment.

AIM

The aim of this study is to compare the perceptions of older patients undergoing haemodialysis treatment and of their next of kin and of nurses regarding patient participation in the context of haemodialysis treatment.

RESEARCH DESIGN

The study adopts an approach that is both comparative and explorative in nature by examining the narratives of patients, nurses and next of kin and by performing critical discourse analysis as outlined by Fairclough.

ETHICAL CONSIDERATIONS

Permission to carry out the research was granted by the Regional Committee for Medical and Health Research Ethics of Mid-Norway and by the participating hospitals. Informed consent and confidentiality were ensured.

FINDINGS

Two discourses were found: (a) the discourse of paternalism with the discursive practices of achieving physiological balance in patients, trusting the healthcare team and being excluded or included in the difficult end-of-life decision-making process, and (b) the discourse of patient participation, with the themes of maintaining patients' quality of life and trusting patients.

CONCLUSION

The participation of older patients and their next of kin was not as well integrated as social practice in dialysis units. The dominant discourse seemed to have an ideology and social practice of paternalism. However, there existed hegemonic struggles for an ideology of patient participation that involved (a) achieving physiological balance in patients versus maintaining patients' quality of life, (b) trusting the healthcare team versus trusting the patient, and (c) being excluded versus included in the difficult end-of-life decision-making process.

Perspectives on death, dying and advance care planning from patients receiving haemodialysis

BACKGROUND

The illness trajectory of End Stage Kidney Disease (ESKD) is not linear therefore it can be difficult for practitioners to know when end-of-life care begins. Advance care planning (ACP) allows patients to take part in decision making, however much of the research conducted stems from North America and Canada where individuals have experience of ACP. The aim of the study was to determine the views of Irish patients receiving haemodialysis, on death, dying and ACP.

METHODS

A quantitative, descriptive design was used with a convenience sample of 50 patients. Data were collected by means of a researcher administered questionnaire and analysed using descriptive statistics.

FINDINGS

The majority of participants were comfortable talking about death, but not necessarily among family, with most desiring medical interventions to prolong life. The control of pain and other symptoms, being physically comfortable and being at peace spiritually were the most important issues at end of life.

CONCLUSION

This study provides an insight into what is important to patients in relation to death, dying and advance care planning.

Perceptions de l’arrêt de la dialyse et des traitements de maintien de la vie chez la clientèle québécoise en hémodialyse hospitalière: comparaison selon l’âge

The End-Stage Renal Disease population is aging. Considering that hemodialysis is a treatment that maintains and prolongs life, this descriptive-comparative study looks at the perceptions of patients according to age group -<65 years, n=121 and ≥65 years, n=123, as it pertains to dialysis treatment cessation and life-sustaining treatments.Results:Older patients are more indecisive as to what dialysis treatment cessation may actually represent for them (p=0,01). They expressed a greater need for support from the health care team if they decided to stop dialysis treatments (p=0,02); a greater involvement from the physician (p=0,04); and, in the event patients could not take part in end-of-life decision-making, they would give priority to the wishes of loved ones instead of their own wishes (p=0,01).Conclusion:Advanced care planning is necessary to demystify hemodialysis withdrawal and to support patients and their loved ones through this process.

The next of kin of older people undergoing haemodialysis: a discursive perspective on perceptions of participation

AIM

This paper is a report of a study conducted to explore how the family members of older people who will undergo haemodialysis treatment for the rest of their lives perceive participation.

BACKGROUND

The rights of families to participate in treatment and health care are supported by international law, and by national law in Norway since 1999.

METHOD

This study, which employed an explorative qualitative approach, was carried out in Norway in 2008. Data were derived from transcribed interviews with seven family members underwent critical discourse analysis.

FINDINGS

Three discourse practices about the next of kin perception of participation were found: (1) to care and take control, (2) to struggle for involvement, and (3) to be forgotten and powerless. The next of kin said that they had no dialogue with the healthcare team, and some fought to be included in the decision-making process.

CONCLUSION

The dominant part of the discourse as expressed by the next of kin seems to be a paternalistic ideology. Thus, finding ways to enable the next of kin to participate in the decision-making process seems to be a major challenge for the healthcare team in the dialysis units.

Chronic kidney disease (CKD) in the elderly -- a geriatrician's perspective

Chronic kidney disease (CKD) is becoming increasingly prevalent among many different populations all over the world, including the US and Europe. Its multitude of complications with devastating outcomes leads to a significantly higher risk for cardio-vascular and all-cause mortality in an individual. However, it is clear now that early detection of CKD might not only delay some of the complications but also prevent them. Therefore, various important public health organizations all over the world have turned their focus and attention to CKD and its risk factors, early detection and early intervention. Nevertheless, the general goals in preventing the increase in CKD and its complications are far from being completely achieved. Why is this so? What is the magnitude and complexity of the problem? How is it affecting the population - are there differences in its affection by age, gender or frail elderly versus the robust? Are we modifying the risk factors appropriately and aggressively? Are there subtle differences in managing the risk factors in those on dialysis versus the non-dialysis CKD patients? Is it important to treat anaemia of CKD aggressively, will it make a difference in the disease progression, its complications or to quality of life? What do these unfortunate individuals commonly succumb to? What do we advise patients who refuse dialysis or those who desire dialysis or transplant? Are there useful non-dialytic treatment recommendations for those who refuse dialysis? What is the role of the physicians caring for the elderly with CKD? When should the primary care givers refer a CKD patient to a nephrologist? The key to eventually controlling incident and prevalent CKD and improve quality of life of affected individuals, lies in not only knowing these and many other vital aspects, but also in applying such knowledge compulsively in day-to-day practice by each and every one us. As CKD is increasingly a disease of the elderly with men being affected more, this review details fairly comprehensively the vital aspects of CKD, especially from a primary care geriatrician's practical standpoint.

The creation of an advance care planning process for patients with ESRD

Comprehensive care of patients with end-stage renal disease (ESRD) requires expertise in advance care planning (ACP), including attention to ethical, psychosocial, and spiritual issues related to starting, continuing, withholding, and stopping dialysis therapy. ACP currently is under evolution from a document-driven decision-focused event. This article describes a new approach to ACP that emphasizes a relational patient-centered process that focuses on broader goals of care for a particular dialysis patient with known medical problems and is designed to serve as a guide to help nephrologists, social workers, and other health care professionals explore ACP discussions with their patients with ESRD. Specifically, we define ACP, highlight goals and key features of this facilitated ACP process, and provide an interview guide with examples of questions that can be used to explore the various aspects of ACP with patients and their families. Outcomes of such an ACP process will not be measured by increasing the number of completed advance directives, but by improving satisfaction with the entire end-of-life experience and having outcomes match patient preferences. It is expected that such a process will enhance shared decision making among patient, surrogate, and health care provider and help build strong and intimate relationships that can only serve to enhance end-of-life care. Throughout this process, patients are not abandoned as they confront the realities of declining health and functional status, but rather are supported through their illness and life on dialysis treatment.

Hope and advance care planning in patients with end stage renal disease: qualitative interview study

OBJECTIVE

To understand hope in the context of advance care planning from the perspective of patients with end stage renal disease.

DESIGN

Qualitative in-depth interview study.

SETTING

Outpatient department of a university affiliated nephrology programme.

PARTICIPANTS

19 patients with end stage renal disease purposively selected from the renal insufficiency, haemodialysis, and peritoneal dialysis clinics.

RESULTS

Patients' hopes were highly individualised and were shaped by personal values. They reflected a preoccupation with their daily lives. Participants identified hope as central to the process of advance care planning in that hope helped them to determine future goals of care and provided insight into the perceived benefits of advance care planning and their willingness to engage in end of life discussions. More information earlier in the course of the illness focusing on the impact on daily life, along with empowerment of the patient and enhancing professional and personal relationships, were key factors in sustaining patients' ability to hope. This helped them to imagine possibilities for a future that were consistent with their values and hopes. The reliance on health professionals to initiate end of life discussions and the daily focus of clinical care were seen as potential barriers to hope.

CONCLUSIONS

Facilitated advance care planning through the provision of timely appropriate information can positively enhance rather than diminish patients' hope. Current practices concerning disclosure of prognosis are ethically and psychologically inadequate in that they do not meet the needs of patients.

"Is there life on dialysis?": time and aging in a clinically sustained existence

Increasingly, in the United States, lives are being extended at ever-older ages through the implementation of routine medical procedures such as renal dialysis. This paper discusses the lives and experiences of a number of individuals 70 years of age and older at two dialysis units in California. It considers what kind of life it is that is being sustained and prolonged in these units, the meanings of the time gained through (and lost to) dialysis for older people, and the relationship of "normal" life outside the units to an exceptional state on the inside that some patients see as not-quite-life. Highlighting the unique dimensions of gerontological time on chronic life support, the article offers a phenomenology of the end of life as that end is drawn out, deferred by technological means, and effaced by the ethos and experiential course of dialysis treatment.