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Davison SN, Richardson MM, Roberts GV. Measuring Symptoms Across the Spectrum of Chronic Kidney Disease: Strategies for Incorporation Into Kidney Care. Semin Nephrol 2024; 44:151546. [PMID: 39209557 DOI: 10.1016/j.semnephrol.2024.151546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Abstract
Many people across the spectrum of chronic kidney disease (CKD) experience a large symptom burden. Measuring symptoms can be a way of responding to the concerns of patients and their priorities of care and may help to improve overall outcomes, including health-related quality of life. The objective of this article is to discuss approaches to measuring symptoms across the spectrum of CKD and to highlight strategies to facilitate the incorporation of routine symptom assessment into kidney care. Specifically, we discuss the use of validated patient-reported outcome measures in CKD as they relate to measuring symptoms, including their benefits and limitations, and describe commonly used patient-reported outcome measures. We discuss potential barriers that should be considered when contemplating the development of a program to routinely measure and address symptoms. Finally, we outline a systematic, stepwise approach to measuring symptoms with implementation strategies to address the common barriers. Although the principles outlined in this article can be applied to research and audit, the principal focus is on symptom measurement aimed at informing clinical practice and directly improving patient outcomes.
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Affiliation(s)
- Sara N Davison
- Division of Nephrology and Immunology, Department of Medicine, University of Alberta, Edmonton, Canada.
| | - Michelle M Richardson
- William B. Schwartz Division of Nephrology, Tufts Medical Center and Tufts University School of Medicine, Boston, MA
| | - Glenda V Roberts
- External Relations and Patient Engagement, Kidney Research Institute/Center for Dialysis Innovation, Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA
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Farisco M, Blumblyte IA, Franssen C, Nitsch D, Zecchino I, Capasso G, Hafez G. Cognitive decline related to chronic kidney disease as an exclusion factor from kidney transplantation: results from an international survey. Clin Kidney J 2024; 17:sfae114. [PMID: 38745874 PMCID: PMC11092267 DOI: 10.1093/ckj/sfae114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Indexed: 05/16/2024] Open
Abstract
Background and hypothesis There seems to be a lack of consensus on the necessity and the modality of psychological and specifically cognitive assessment of candidates for kidney transplantation. Both points are often delegated to individual hospitals/centres, whereas international guidelines are inconsistent. We think it is essential to investigate professionals' opinions to advance towards a consistent clinical practice. Methods This paper presents the results of an international survey among clinical professionals, mainly nephrologists from the CONNECT (Cognitive decline in Nephro-Neurology: European Cooperative Target) network and beyond (i.e. from personal contacts of CONNECT members). The survey investigated their opinions about the question of whether cognitive decline in patients with chronic kidney disease may affect their eligibility for kidney transplantation. Results Our results show that most clinicians working with patients affected by chronic kidney disease think that cognitive decline may challenge their eligibility for transplantation despite data that suggest that, in some patients, cognitive problems improve after kidney transplantation. Conclusion We conclude that three needs emerge as particularly pressing: defining agreed-on standards for a multifaceted and multifactorial assessment (i.e. including both clinical/medical and psychosocial factors) of candidates with chronic kidney disease to kidney transplantation; further investigating empirically the causal connection between chronic kidney disease and cognition; and further investigating empirically the possible partial reversibility of cognitive decline after kidney transplantation.
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Affiliation(s)
- Michele Farisco
- Department of Public Health and Caring Sciences, Centre for Research Ethics and Bioethics, Uppsala University, Uppsala, Sweden
- Biogem Molecular Biology and Genetics Research Institute, Ariano Irpino (AV), Italy
| | - Inga A Blumblyte
- Department of Nephrology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Casper Franssen
- Department of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Dorothea Nitsch
- UK Renal Registry, UK Kidney Association, Bristol, UK
- Department of Non-communicable Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
- Department of Nephrology, Royal Free London NHS Foundation Trust, London, UK
| | - Irene Zecchino
- Department of Science and Technology, University of Sannio, Benevento, Italy
| | - Giovambattista Capasso
- Department of Public Health and Caring Sciences, Centre for Research Ethics and Bioethics, Uppsala University, Uppsala, Sweden
- Department Translational Medical Science, University Campania Luigi Vanvitelli, Naples, Italy
| | - Gaye Hafez
- Department of Pharmacology, Faculty of Pharmacy, Altinbas University, Istanbul, Turkey
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Giordano A, De Panfilis L, Perin M, Servidio L, Cascioli M, Grasso MG, Lugaresi A, Pucci E, Veronese S, Solari A. Advance Care Planning in Neurodegenerative Disorders: A Scoping Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:803. [PMID: 35055625 PMCID: PMC8775509 DOI: 10.3390/ijerph19020803] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Revised: 01/04/2022] [Accepted: 01/07/2022] [Indexed: 01/27/2023]
Abstract
Advance care planning (ACP) is increasingly acknowledged as a key step to enable patients to define their goals/preferences for future medical care, together with their carers and health professionals. We aimed to map the evidence on ACP in neurodegenerative disorders. We conducted a scoping review by searching PubMed (inception-December 28, 2020) in addition to trial, review, and dissertation registers. From 9367 records, we included 53 studies, mostly conducted in Europe (45%) and US-Canada (41%), within the last five years. Twenty-six percent of studies were qualitative, followed by observational (21%), reviews (19%), randomized controlled trials (RCTs, 19%), quasi-experimental (11%), and mixed-methods (4%). Two-thirds of studies addressed dementia, followed by amyotrophic lateral sclerosis (13%), and brain tumors (9%). The RCT interventions (all in dementia) consisted of educational programs, facilitated discussions, or videos for patients and/or carers. In conclusion, more research is needed to investigate barriers and facilitators of ACP uptake, as well as to develop/test interventions in almost all the neurodegenerative disorders. A common set of outcome measures targeting each discrete ACP behavior, and validated across the different diseases and cultures is also needed.
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Affiliation(s)
- Andrea Giordano
- Unit of Neuroepidemiology, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20133 Milan, Italy; (A.G.); (L.S.)
| | - Ludovica De Panfilis
- Bioethics Unit, Azienda USL-IRCCS di Reggio Emilia, 42100 Reggio Emilia, Italy; (L.D.P.); (M.P.)
| | - Marta Perin
- Bioethics Unit, Azienda USL-IRCCS di Reggio Emilia, 42100 Reggio Emilia, Italy; (L.D.P.); (M.P.)
- PhD Program in Clinical and Experimental Medicine, University of Modena and Reggio Emilia, 41100 Modena, Italy
| | - Laura Servidio
- Unit of Neuroepidemiology, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20133 Milan, Italy; (A.G.); (L.S.)
| | - Marta Cascioli
- Hospice ‘La Torre sul Colle’, Azienda USL Umbria 2, 06049 Spoleto, Italy;
| | | | - Alessandra Lugaresi
- Dipartimento di Scienze Biomediche e Neuromotorie, Università di Bologna, 40126 Bologna, Italy;
- IRCCS Istituto delle Scienze Neurologiche di Bologna, 40139 Bologna, Italy
| | - Eugenio Pucci
- UOC Neurologia, ASUR Marche-AV4, 63900 Fermo, Italy;
| | | | - Alessandra Solari
- Unit of Neuroepidemiology, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20133 Milan, Italy; (A.G.); (L.S.)
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Penninger LP, Collins SG. Saying Goodbye. PHYSICIAN ASSISTANT CLINICS 2022. [DOI: 10.1016/j.cpha.2021.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Parsons JA, Taylor DM, Caskey FJ, Ives J. Ethical Duties of Nephrologists: When Patients Are Nonadherent to Treatment. Semin Nephrol 2021; 41:262-271. [PMID: 34330366 DOI: 10.1016/j.semnephrol.2021.05.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Accepted: 05/13/2021] [Indexed: 11/17/2022]
Abstract
When providing care, nephrologists are subject to various ethical duties. Beyond the Hippocratic notion of doing no harm, nephrologists also have duties to respect their patients' autonomy and dignity, to meet their patients' care goals in the least invasive way, to act impartially, and, ultimately, to do what is (clinically) beneficial for their patients. Juggling these often-conflicting duties can be challenging at the best of times, but can prove especially difficult when patients are not fully adherent to treatment. When a patient's nonadherence begins to cause harm to themselves and/or others, it may be questioned whether discontinuation of care is appropriate. We discuss how nephrologists can meet their ethical duties when faced with nonadherence in patients undergoing hemodialysis, including episodic extreme agitation, poor renal diet, missed hemodialysis sessions, and emergency presentations brought on by nonadherence. Furthermore, we consider the impact of cognitive impairment and provider-family conflict when making care decisions in a nonadherence context, as well as how the coronavirus disease 2019 pandemic might affect responses to nonadherence. Suggestions are provided for ethically informed responses, prioritizing a patient-narrative approach that is attentive to patients' values and preferences, multidisciplinarity, and the use of behavioral contracts and/or technology where appropriate.
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Affiliation(s)
| | - Dominic M Taylor
- Bristol Medical School, University of Bristol, Bristol, UK; Renal Unit, Southmead Hospital, Bristol, UK
| | - Fergus J Caskey
- Bristol Medical School, University of Bristol, Bristol, UK; Renal Unit, Southmead Hospital, Bristol, UK
| | - Jonathan Ives
- Bristol Medical School, University of Bristol, Bristol, UK
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Parsons JA, Ives J. Dialysis decisions concerning cognitively impaired adults: a scoping literature review. BMC Med Ethics 2021; 22:24. [PMID: 33663482 PMCID: PMC7932834 DOI: 10.1186/s12910-021-00591-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 02/22/2021] [Indexed: 02/07/2023] Open
Abstract
Background Chronic kidney disease is a significant cause of global deaths. Those who progress to end-stage kidney disease often commence dialysis as a life-extending treatment. For cognitively impaired patients, the decision as to whether they commence dialysis will fall to someone else. This scoping review was conducted to map existing literature pertaining to how decisions about dialysis are and should be made with, for, and on behalf of adult patients who lack decision-making capacity. In doing so, it forms the basis of a larger body of work that is exploring how these decisions ought to be made. Methods To identify relevant papers, searches were conducted on Ovid MEDLINE(R), Embase, PsychINFO, The Cochrane Library, and Web of Science. Inclusion criteria were then applied, requiring that papers: report on empirical studies about how decisions about dialysis are made and/or discuss how decisions about dialysis should be made with, for, and on behalf of adult patients who lack decision-making capacity; be published from 1961 onwards; and be published in English. This resulted in 27 papers eligible for inclusion. Results Of note, the majority of papers originated in the United States. There was wide variation across the included papers. Extracted data were grouped under the following themes: involving various parties (patient involvement, family dominance, and wider communication); objectivity about care options (including difficulties with family detachment); cultural sensitivity; medical versus non-medical factors; managing nonadherent patients; and the role and prevalence of substituted judgement. The literature shows that there is inconsistency in the principles and processes surrounding decisions made about dialysis with, for, and on behalf of adult patients who lack decision-making capacity. Conclusions This scoping review demonstrates that there is significant variation in both the practice and theory of dialysis decision making with, for, and on behalf of cognitively impaired adult patients. Complexity arises in considering who should get a say, how influential their say should be in a decision, and what factors are most relevant to the decision. A lack of up-to-date literature exploring this issue is highlighted, with this scoping review providing a useful groundwork from which further research can be undertaken.
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Affiliation(s)
- Jordan A Parsons
- Centre for Ethics in Medicine, Bristol Medical School, University of Bristol, Bristol, UK.
| | - Jonathan Ives
- Centre for Ethics in Medicine, Bristol Medical School, University of Bristol, Bristol, UK
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Martin DE, Harris DCH, Jha V, Segantini L, Demme RA, Le TH, McCann L, Sands JM, Vong G, Wolpe PR, Fontana M, London GM, Vanderhaegen B, Vanholder R. Ethical challenges in nephrology: a call for action. Nat Rev Nephrol 2020; 16:603-613. [PMID: 32587403 DOI: 10.1038/s41581-020-0295-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/17/2020] [Indexed: 12/14/2022]
Abstract
The American Society of Nephrology, the European Renal Association-European Dialysis and Transplant Association and the International Society of Nephrology Joint Working Group on Ethical Issues in Nephrology have identified ten broad areas of ethical concern as priority challenges that require collaborative action. Here, we describe these challenges - equity in access to kidney failure care, avoiding futile dialysis, reducing dialysis costs, shared decision-making in kidney failure care, living donor risk evaluation and decision-making, priority setting in kidney disease prevention and care, the ethical implications of genetic kidney diseases, responsible advocacy for kidney health and management of conflicts of interest - with the aim of highlighting the need for ethical analysis of specific issues, as well as for the development of tools and training to support clinicians who treat patients with kidney disease in practising ethically and contributing to ethical policy-making.
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Affiliation(s)
- Dominique E Martin
- School of Medicine, Deakin University, Geelong Waurn Ponds Campus, Geelong, VIC, Australia.
| | - David C H Harris
- University of Sydney at Westmead Hospital, Westmead, NSW, Australia
| | - Vivekanand Jha
- George Institute for Global Health, UNSW, New Delhi, India
- University of Oxford, Oxford, UK
- Manipal Academy of Higher Education, Manipal, India
| | - Luca Segantini
- International Society of Nephrology, Brussels, Belgium
- European Society for Organ Transplantation - ESOT c/o ESOT, Padova, Italy
| | - Richard A Demme
- Renal Division and Department of Medical Humanities and Bioethics, University of Rochester School of Medicine, Rochester, NY, USA
| | - Thu H Le
- Nephrology Division, Department of Medicine, University of Rochester School of Medicine, Rochester, NY, USA
| | - Laura McCann
- American Society of Nephrology, Washington, DC, USA
| | - Jeff M Sands
- Renal Division, Emory University School of Medicine, Atlanta, GA, USA
| | - Gerard Vong
- Center for Ethics, Emory University, Atlanta, GA, USA
| | | | - Monica Fontana
- European Renal Association - European Dialysis and Transplant Association, Parma, Italy
| | - Gerard M London
- Manhes Hospital, Nephrology Department GEPIR, Fleury-Mérogis, France
| | | | - Raymond Vanholder
- Nephrology Section, Department of Internal Medicine and Pediatrics, University Hospital, Corneel Heymanslaan 10, B9000, Gent, Belgium
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Alshamsi FE, Chaaban A, Alrukhaimi M, Bernieh B, Bakoush O. Provision of renal care for patients with end stage kidney disease in persistent vegetative state, in United Arab Emirates: a national survey of renal physicians. Libyan J Med 2018; 13:1490610. [PMID: 29979643 PMCID: PMC6041784 DOI: 10.1080/19932820.2018.1490610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/29/2022] Open
Abstract
Patients with end stage kidney disease (ESKD) with severely impaired cognitive function have no survival benefit from dialysis. We therefore undertook a survey to explore the renal physicians' practices of withholding and withdrawal of dialysis treatment in vegetative state patients in the United Arab Emirates (UAE). A cross sectional survey of 29 nephrology practices in UAE exploring physicians' practices in making decisions of withholding and withdrawal of dialysis treatment during provision end-of-life care for patients in persistent vegetative state (PVS).The majority of participants practice in governmental non-for-profit dialysis units (79%), and think they are well prepared to make decision with patients and family on issues of dialysis withdrawal and withholding (69%). If a chronic dialysis patient became permanently unconscious only few respondents (17%) indicated probability of stopping dialysis. On the other hand, more respondents (48%) reported that dialysis is likely to be withheld in PVS patients who develop kidney failure. In high risk or poor prognosis ESKD patients and given how likely they would consider each option independently, respondents reported they are likely to consider time-limited dialysis in 78% of the time followed by stopping (46%) or forgoing (27%) dialysis. Majority of the participants perceived that their decisions in providing renal care for PVS patients in UAE were influenced by the family sociocultural beliefs (76% of participants), the current hospital policies (72% of participants), and by Islamic beliefs (66% of participants). Only few perceived access to palliative care (30%) and treatment cost (17%) to have an impact on their decision making.Decisions of initiation and continuation of dialysis treatment to ESKD patients in PVS are prevalent among nephrology practices in UAE. Development of local guidelines based on the societal values along with early integration of palliative kidney failure management care would be required to improve the quality of provision of end-of-life renal care in UAE. ABBREVIATIONS ESKD: stage kidney disease; UAE: United Arab Emirates; PVS: persistent vegetative state; RPA: Renal Physicians Association; ASN: American Society of Nephrology; EMAN: Emirates Medical Association Nephrology Society; CPR: cardiopulmonary resuscitation.
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Affiliation(s)
| | - Ahmed Chaaban
- b Nephrology Department , Tawam Hopsital , United Arab Emirates
| | - Mona Alrukhaimi
- c Department of Internal Medicine , Dubai Medical College , Dubai , United Arab Emirates
| | - Bassam Bernieh
- b Nephrology Department , Tawam Hopsital , United Arab Emirates
| | - Omran Bakoush
- a College of Medicine , United Arab Emirates University , United Arab Emirates
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Zhu L, Ding Y. RGC-32 induces transition of pancreatic cancer to epithelial mesenchyme in vivo. Pancreatology 2018; 18:572-576. [PMID: 29886073 DOI: 10.1016/j.pan.2018.05.480] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 05/15/2018] [Accepted: 05/17/2018] [Indexed: 12/11/2022]
Abstract
OBJECTIVES This study was undertaken to investigate the induction of transition of pancreatic cancer to epithelial mesenchyme by RGC-32. METHODS Primary human pancreatic cancer cell line BXPC-3 was transfected with lentivirus overexpressing the response gene to complement-32 gene (RGC-32) and used to induce tumor in mice. The tumor sizes were measured and the expression of cytokeratin, e-cadherin and vimentin at mRNA using real time PCR and at protein levels by Western blot. RESULTS Compared with the control, mice inoculated with the cells transfected with empty vector had similar tumor size while those inoculated with the cells transfected with RGC-32 expressing virus had significantly greater tumor size. HE staining showed that tumors were formed in all treatments. Molecular analyses showed that there was no difference in the expression of the cytokeratin, e-cadherin and vimentin genes at mRNA and protein levels between control and empty vector groups. However, mice derived from cells transfected with RGC-32 expressing virus had reduced cytokeratin and e-cadherin expression and increased vimentin expression. CONCLUSIONS These data suggest that RGC-32 promotes the proliferation of pancreatic cancer and induces the epithelial-mesenchymal transition (EMT). It would be a future direction of research to investigate the regulatory mechanism of signal molecules downstream RGC-32 on EMT-related transcription factors and deliberate the role of RGC-32 in tumorigenicity. As a result, RGC-32 may become a new therapeutic target for cancers.
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Affiliation(s)
- Liang Zhu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, 330006, Jiangxi, China.
| | - Ying Ding
- Department of Plastic and Cosmetic Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, 330006, Jiangxi, China
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Kahrass H, Strech D, Mertz M. The Full Spectrum of Clinical Ethical Issues in Kidney Failure. Findings of a Systematic Qualitative Review. PLoS One 2016; 11:e0149357. [PMID: 26938863 PMCID: PMC4777282 DOI: 10.1371/journal.pone.0149357] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Accepted: 01/29/2016] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND When treating patients with kidney failure, unavoidable ethical issues often arise. Current clinical practice guidelines some of them, but lack comprehensive information about the full range of relevant ethical issues in kidney failure. A systematic literature review of such ethical issues supports medical professionalism in nephrology, and offers a solid evidential base for efforts that aim to improve ethical conduct in health care. AIM To identify the full spectrum of clinical ethical issues that can arise for patients with kidney failure in a systematic and transparent manner. METHOD A systematic review in Medline (publications in English or German between 2000 and 2014) and Google Books (with no restrictions) was conducted. Ethical issues were identified by qualitative text analysis and normative analysis. RESULTS The literature review retrieved 106 references that together mentioned 27 ethical issues in clinical care of kidney failure. This set of ethical issues was structured into a matrix consisting of seven major categories and further first and second-order categories. CONCLUSIONS The systematically-derived matrix helps raise awareness and understanding of the complexity of ethical issues in kidney failure. It can be used to identify ethical issues that should be addressed in specific training programs for clinicians, clinical practice guidelines, or other types of policies dealing with kidney failure.
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Affiliation(s)
- Hannes Kahrass
- Institute for History, Ethics and Philosophy in Medicine, Hannover Medical School, Hannover, Germany
| | - Daniel Strech
- Institute for History, Ethics and Philosophy in Medicine, Hannover Medical School, Hannover, Germany
| | - Marcel Mertz
- Institute for History, Ethics and Philosophy in Medicine, Hannover Medical School, Hannover, Germany
- Center for Ethics, University Hospital Cologne, Cologne, Germany
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Song MK, Hanson LC, Gilet CA, Jo M, Reed TJ, Hladik GA. Management of ethical issues related to care of seriously ill dialysis patients in free-standing facilities. J Pain Symptom Manage 2014; 48:343-52. [PMID: 24411183 DOI: 10.1016/j.jpainsymman.2013.09.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2013] [Revised: 09/09/2013] [Accepted: 09/15/2013] [Indexed: 11/22/2022]
Abstract
CONTEXT There are few data on the frequency and current management of clinical ethical issues related to care of seriously ill dialysis patients in free-standing dialysis facilities. OBJECTIVES To examine the extent of clinical ethical challenges experienced by care providers in free-standing facilities and their perceptions about how those issues are managed. METHODS A total of 183 care providers recruited from 15 facilities in North Carolina completed a survey regarding the occurrence and management of ethical issues in the past year. Care plan meetings were observed at four of the facilities for three consecutive months. Also, current policies and procedures at each of the facilities were reviewed. RESULTS The two most frequently experienced challenges involved dialyzing frail patients with multiple comorbidities and caring for disruptive/difficult patients. The most common ways of managing ethical issues were discussions in care plan meetings (n = 47) or discussions with the clinic manager (n = 47). Although policies were in place to guide management of some of the challenges, respondents were often not aware of those policies. Also, although participants reported that ethical issues related to dialyzing undocumented immigrants were fairly common, no facility had a policy for managing this challenge. Participants suggested that all staff obtain training in clinical ethics and communication skills, facilities develop ethics teams, and there be clear policies to guide management of ethical challenges. CONCLUSION The scope of ethical challenges was extensive, how these challenges were managed varied widely, and there were limited resources for assistance. Multifaceted efforts, encompassing endeavors at the individual, facility, organization, and national levels, are needed to support staff in improving the management of ethical challenges in dialysis facilities.
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Affiliation(s)
- Mi-Kyung Song
- School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.
| | - Laura C Hanson
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Constance A Gilet
- UNC Kidney Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Minjeong Jo
- School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Teresa J Reed
- School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Gerald A Hladik
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA; UNC Kidney Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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13
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Withdrawal from long-term hemodialysis in patients with end-stage renal disease in Taiwan. J Formos Med Assoc 2013; 112:589-99. [DOI: 10.1016/j.jfma.2013.04.009] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2013] [Revised: 03/07/2013] [Accepted: 04/17/2013] [Indexed: 11/19/2022] Open
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van de Luijtgaarden MWM, Noordzij M, van Biesen W, Couchoud C, Cancarini G, Bos WJW, Dekker FW, Gorriz JL, Iatrou C, Wanner C, Finne P, Stojceva-Taneva O, Cala S, Stel VS, Tomson C, Jager KJ. Conservative care in Europe--nephrologists' experience with the decision not to start renal replacement therapy. Nephrol Dial Transplant 2013; 28:2604-12. [PMID: 24013682 DOI: 10.1093/ndt/gft287] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND For some patients with end-stage renal disease (ESRD), providing conservative care until death may be an acceptable alternative for renal replacement therapy (RRT). We aimed to estimate the occurrence of conservative care in Europe and evaluated opinions about which factors nephrologists consider important in their decision not to offer RRT. METHODS With a web-based survey sent to nephrologists in 11 European countries, we inquired how often RRT was not started in 2009 and how specific factors would influence the nephrologists' decision to provide conservative care. We compared subgroups by nephrologist and facility characteristics using chi-square tests and Mann-Whitney U tests. RESULTS We received 433 responses. Nephrologists decided to offer conservative care in 10% of their patients [interquartile range (IQR) 5-20%]. An additional 5% (IQR 2-10%) of the patients chose conservative care as they refused when nephrologists intended to start RRT. Patient preference (93%), severe clinical conditions (93%), vascular dementia (84%) and low physical functional status (75%) were considered extremely or quite important in the nephrologists' decision to provide conservative care. Nephrologists from countries with a low incidence of RRT, not-for-profit centres and public centres more often scored these factors as extremely or quite important than their counterparts from high-incidence countries, for-profit centres and private centres. CONCLUSIONS Nephrologists estimated conservative care was provided to up to 15% of their patients in 2009. The presence of severe clinical conditions, vascular dementia and a low physical functional status are important factors in the decision-making not to start RRT. Patient preference was considered as a very important factor, confirming the importance of extensive patient education and shared decision-making.
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Affiliation(s)
- Moniek W M van de Luijtgaarden
- ERA-EDTA Registry, Department of Medical Informatics, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
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Murtagh FE, Spagnolo AG, Panocchia N, Gambaro G. Conservative (non dialytic) management of end-stage renal disease and withdrawal of dialysis. PROGRESS IN PALLIATIVE CARE 2013. [DOI: 10.1179/096992609x12455871937143] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Germain MJ, Davison SN, Moss AH. When Enough Is Enough: The Nephrologist's Responsibility in Ordering Dialysis Treatments. Am J Kidney Dis 2011; 58:135-43. [DOI: 10.1053/j.ajkd.2011.03.019] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2011] [Accepted: 03/18/2011] [Indexed: 11/11/2022]
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Fassett RG, Robertson IK, Mace R, Youl L, Challenor S, Bull R. Palliative care in end-stage kidney disease. Nephrology (Carlton) 2011; 16:4-12. [PMID: 21175971 DOI: 10.1111/j.1440-1797.2010.01409.x] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Patients with end-stage kidney disease have significantly increased morbidity and mortality. While greater attention has been focused on advanced care planning, end-of-life decisions, conservative therapy and withdrawal from dialysis these must be supported by adequate palliative care incorporating symptom control. With the increase in the elderly, with their inherent comorbidities, accepted onto dialysis, patients, their nephrologists, families and multidisciplinary teams, are often faced with end-of-life decisions and the provision of palliative care. While dialysis may offer a better quality and quantity of life compared with conservative management, this may not always be the case; hence the patient is entitled to be well-informed of all options and potential outcomes before embarking on such therapy. They should be assured of adequate symptom control and palliative care whichever option is selected. No randomized controlled trials have been conducted in this area and only a small number of observational studies provide guidance; thus predicting which patients will have poor outcomes is problematic. Those undertaking dialysis may benefit from being fully aware of their choices between active and conservative treatment should their functional status seriously deteriorate and this should be shared with caregivers. This clarifies treatment pathways and reduces the ambiguity surrounding decision making. If conservative therapy or withdrawal from dialysis is chosen, each should be supported by palliative care. The objective of this review is to summarize published studies and evidence-based guidelines, core curricula, position statements, standards and tools in palliative care in end-stage kidney disease.
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Affiliation(s)
- Robert G Fassett
- Renal Research, Royal Brisbane and Women's Hospital, School of Medicine, The University of Queensland, Brisbane, St. Lucia, Queensland, Australia.
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Guessous I, Duhn V, McClellan W. Breast Cancer Screening and Dialysis: Too Much or Too Little. Am J Kidney Dis 2008; 52:830-3. [DOI: 10.1053/j.ajkd.2008.09.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2008] [Accepted: 09/18/2008] [Indexed: 11/11/2022]
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Nulsen RS, Yaqoob MM, Mahon A, Stoby-Fields M, Kelly M, Varagunam M. PREVALENCE OF COGNITIVE IMPAIRMENT IN PATIENTS ATTENDING PRE-DIALYSIS CLINIC. J Ren Care 2008; 34:121-6. [DOI: 10.1111/j.1755-6686.2008.00028.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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