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Marcussen J, Madsen R, Bonner A, Agerskov H. Perceptions of haemodialysis nurses regarding patients' and families' loss and grief. J Ren Care 2024; 50:223-231. [PMID: 37717218 DOI: 10.1111/jorc.12479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 08/21/2023] [Accepted: 09/01/2023] [Indexed: 09/19/2023]
Abstract
BACKGROUND The experience of loss and grief in patients' lives with life-long treatment in haemodialysis, and in their families' lives is a major cause of mental health problems. In practice, nurses often describe a lack of time and limited knowledge of how to provide nursing care in situations of loss and grief, thus finding out from nurses' perspectives of what competencies they need to provide care would be useful for the development of nursing practice. OBJECTIVES To develop knowledge in a nursing perspective of competencies to provide care for patients and their families, who experience grief linked to loss due to kidney failure, haemodialysis and/or death. DESIGN The study took a phenomenological-hermeneutical approach. Semi-structured interviews were conducted 12 nurses caring for patients receiving haemodialysis with no kidney transplantation option and family members. Ricoeur's interpretation theory involving naïve reading, structural analysis and critical interpretation and discussion was used for analysis. RESULTS Four themes emerged of nurse's experiences: (1) patient's loss and grief in everyday life, (2) dealing with supportive conversations when caring for patients, (3) families' losses are resulting in grief reactions and (4) importance of close relationships when caring for families. CONCLUSIONS To nurses, patients on haemodialysis and their families have multiple loss and grief experiences. Nurses' working in kidney care need to develop competencies to support patients and families to cope with grief and loss. Further research is needed to develop these competencies and then to implement in education and practice.
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Affiliation(s)
- Jette Marcussen
- OPEN, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Health and Nature, University of Greenland, Nuuk, Greenland
- Faculty of Health Sciences, Health Science Research Center, UCL University College, Niels Bohrs Alle 1, Odense M, Denmark
| | - Rikke Madsen
- Faculty of Health Sciences, Faculty of Nursing, Health Science Research Center, UCL University College, Vejle, Denmark
| | - Ann Bonner
- School of Nursing and Midwifery, Griffith University, Brisbane, QLD, Australia
- Kidney Health Service, Townsvill University Hospital, Townsville, QLD, Australia
- Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Hanne Agerskov
- Department of Nephrology, Odense University Hospital, Odense, Denmark
- Department of Clinical Institute and Family Focused Health Care Research Centre, University of Southern Denmark, Odense, Denmark
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Canada KE, Vogelsmeier AA, Popejoy LL, Powell K, Brandt L, Rantz M. Exploring Hospital Transfers for Long-Stay Nursing Home Residents With End-Stage Renal Disease. J Nurs Care Qual 2024; 39:232-238. [PMID: 38198671 DOI: 10.1097/ncq.0000000000000758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2024]
Abstract
BACKGROUND Nursing home residents with end-stage renal disease (ESRD) are an understudied, yet growing population within nursing homes. PURPOSE To describe hospital transfers for nursing home residents diagnosed with ESRD and receiving hemodialysis. METHODS Data were analyzed for residents with ESRD transferred to the hospital between October 2016 and September 2020 (n = 219). Descriptive statistics, bivariate analyses, logistic regression, and content analysis were used for analysis. RESULTS Clinical factors associated with transfers included abnormal vitals, altered mental state, and pain. Other factors included lack of care planning and advance directives, provider communication, resident/family preferences, missing/refusing dialysis, and facility resources. The odds of an observation/emergency department only visit was 2.02 times larger when transferred from the dialysis clinic. CONCLUSIONS Advance care planning and coordinated care between nursing home and dialysis clinics are needed along with proactive planning when residents miss dialysis or experience a condition change at the dialysis clinic.
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Affiliation(s)
- Kelli E Canada
- Author Affiliations: School of Social Work, University of Missouri, Columbia (Dr Canada); Sinclair School of Nursing, University of Missouri, Columbia (Drs Vogelsmeier, Popejoy, Powell, and Rantz); and University of Missouri Center for Health Ethics, Columbia (Dr Brandt)
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Kanakubo Y, Kurita N, Ukai M, Aita T, Inanaga R, Kawaji A, Toishi T, Matsunami M, Munakata Y, Suzuki T, Okada T. Association between person-centred care quality and advance care planning participation in haemodialysis. BMJ Support Palliat Care 2024:spcare-2024-004831. [PMID: 38429114 DOI: 10.1136/spcare-2024-004831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 02/15/2024] [Indexed: 03/03/2024]
Abstract
OBJECTIVE Person-centred care (PCC), which incorporates patients' preferences and values for medical care and their life, has been proposed in decision-making for promoting advance care planning (ACP) among patients with kidney failure. Therefore, we aimed to examine variations in PCC across facilities and the association between PCC and ACP participation. METHODS This multicentre cross-sectional study included Japanese adults undergoing outpatient haemodialysis at six dialysis centres. The main exposure was PCC, measured using the 13-item Japanese version of the Primary Care Assessment Tool-short form. The main outcome was ACP participation as defined by discussion with the attending physician or written documentation or notes regarding treatment preferences. A general linear model was used to examine the covariates of the quality of PCC. Modified Poisson regression models were used to examine the associations of ACP participation. RESULTS A total of 453 individuals were analysed; 26.3% of them participated in ACP. Higher PCC was associated with greater ACP participation in a dose-response manner (adjusted prevalence ratios for the first to fourth quartiles: 1.36, 2.31, 2.64 and 3.10, respectively) in respondents with usual source of care (USC) than in those without USC. Among the PCC subdomains, first contact, longitudinality, comprehensiveness (services provided) and community orientation were particularly associated with ACP participation. A maximum of 12.0 points of facility variation was noted in the quality of PCC. CONCLUSIONS High quality of PCC was associated with ACP participation. The substantial disparity in PCC between facilities provides an opportunity to revisit the quality improvement in PCC.
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Affiliation(s)
- Yusuke Kanakubo
- Tessyoukai Kameda Family Clinic Tateyama, Tateyama-city, Chiba, Japan
- Division of Clinical Epidemiology, Research Center for Medical Sciences, The Jikei University School of Medicine, Minato-ku, Tokyo, Japan
| | - Noriaki Kurita
- Department of Clinical Epidemiology, Graduate School of Medicine, Fukushima Medical University, Fukushima-city, Fukushima, Japan
- Department of Innovative Research and Education for Clinicians and Trainees (DiRECT), Fukushima Medical University Hospital, Fukushima-city, Fukushima, Japan
| | - Mamiko Ukai
- Tessyoukai Kameda Family Clinic Tateyama, Tateyama-city, Chiba, Japan
| | - Tetsuro Aita
- Department of Clinical Epidemiology, Graduate School of Medicine, Fukushima Medical University, Fukushima-city, Fukushima, Japan
- Department of General Internal Medicine, Fukushima Medical University Hospital, Fukushima-city, Fukushima, Japan
| | - Ryohei Inanaga
- Department of Clinical Epidemiology, Graduate School of Medicine, Fukushima Medical University, Fukushima-city, Fukushima, Japan
- Department of Nephrology, Shin-Yurigaoka General Hospital, Kawasaki-city, Kanagawa, Japan
| | - Atsuro Kawaji
- Department of Nephrology, Kameda Medical Center, Kamogawa-city, Chiba, Japan
| | - Takumi Toishi
- Department of Nephrology, Kameda Medical Center, Kamogawa-city, Chiba, Japan
| | - Masatoshi Matsunami
- Department of Clinical Epidemiology, Graduate School of Medicine, Fukushima Medical University, Fukushima-city, Fukushima, Japan
- Department of Nephrology, Kameda Medical Center, Kamogawa-city, Chiba, Japan
| | - Yu Munakata
- Munakata Clinic, Mobara-city, Chiba, Japan
- Chikuseikai Munakata Clinic, Shinjuku-ku, Tokyo, Japan
| | - Tomo Suzuki
- Department of Clinical Epidemiology, Graduate School of Medicine, Fukushima Medical University, Fukushima-city, Fukushima, Japan
- Department of Nephrology, Kameda Medical Center, Kamogawa-city, Chiba, Japan
| | - Tadao Okada
- Tessyoukai Kameda Family Clinic Tateyama, Tateyama-city, Chiba, Japan
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Davison SN, Pommer W, Brown MA, Douglas CA, Gelfand SL, Gueco IP, Hole BD, Homma S, Kazancıoğlu RT, Kitamura H, Koubar SH, Krause R, Li KC, Lowney AC, Nagaraju SP, Niang A, Obrador GT, Ohtake Y, Schell JO, Scherer JS, Smyth B, Tamba K, Vallath N, Wearne N, Zakharova E, Zúñiga C, Brennan FP. Conservative kidney management and kidney supportive care: core components of integrated care for people with kidney failure. Kidney Int 2024; 105:35-45. [PMID: 38182300 DOI: 10.1016/j.kint.2023.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 09/20/2023] [Accepted: 10/02/2023] [Indexed: 01/07/2024]
Abstract
Integrated kidney care requires synergistic linkage between preventative care for people at risk for chronic kidney disease and health services providing care for people with kidney disease, ensuring holistic and coordinated care as people transition between acute and chronic kidney disease and the 3 modalities of kidney failure management: conservative kidney management, transplantation, and dialysis. People with kidney failure have many supportive care needs throughout their illness, regardless of treatment modality. Kidney supportive care is therefore a vital part of this integrated framework, but is nonexistent, poorly developed, and/or poorly integrated with kidney care in many settings, especially in low- and middle-income countries. To address this, the International Society of Nephrology has (i) coordinated the development of consensus definitions of conservative kidney management and kidney supportive care to promote international understanding and awareness of these active treatments; and (ii) identified key considerations for the development and expansion of conservative kidney management and kidney supportive care programs, especially in low resource settings, where access to kidney replacement therapy is restricted or not available. This article presents the definitions for conservative kidney management and kidney supportive care; describes their core components with some illustrative examples to highlight key points; and describes some of the additional considerations for delivering conservative kidney management and kidney supportive care in low resource settings.
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Affiliation(s)
- Sara N Davison
- Division of Nephrology and Immunology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.
| | - Wolfgang Pommer
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, Berlin, Germany; Kuratorium für Dialyse und Nierentransplantation, Neu-Isenburg, Germany
| | - Mark A Brown
- Department of Renal Medicine, St George Hospital, Kogarah, Australia; School of Clinical Medicine, University of New South Wales, Kogarah, Australia
| | - Claire A Douglas
- Department of Renal Medicine, Ninewells Hospital, Dundee, Scotland, UK
| | - Samantha L Gelfand
- Division of Renal (Kidney) Medicine, Department of Psychosocial Oncology and Palliative Care, Brigham and Women's Hospital, Boston, Massachusetts, USA; Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA
| | - Irmingarda P Gueco
- Section of Nephrology, The Medical City, Pasig City, National Capital Region, Philippines
| | - Barnaby D Hole
- Department of Population Health, University of Bristol, Bristol, UK
| | - Sumiko Homma
- Department of Nephrology, Koga Red Cross Hospital, Koga, Ibaraki, Japan
| | - Rümeyza T Kazancıoğlu
- Division of Nephrology, Faculty of Medicine, Bezmialem Vakif University, Istanbul, Türkiye
| | - Harumi Kitamura
- Department of Clinical Quality Management, Osaka University Hospital, Osaka, Japan
| | - Sahar H Koubar
- Division of Nephrology and Hypertension, Department of Internal Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Rene Krause
- Division of Interdisciplinary Palliative Care and Medicine, Department of Family Community and Emergency Care, University of Cape Town, Cape Town, South Africa
| | - Kelly C Li
- Department of Renal Medicine, St George Hospital, Kogarah, Australia; School of Clinical Medicine, University of New South Wales, Kogarah, Australia
| | - Aoife C Lowney
- Department of Palliative Medicine, Marymount University Hospital and Hospice, Cork, Ireland; Department of Palliative Medicine, Cork University Hospital, Cork, Ireland; Department of Palliative Medicine, University College Cork, Cork, Ireland
| | - Shankar P Nagaraju
- Department of Nephrology, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, India
| | - Abdou Niang
- Nephrology Department, Cheikh Anta Diop University, Dakar, Senegal
| | - Gregorio T Obrador
- Department of Biostatistics and Public Health, Universidad Panamericana School of Medicine, Mexico City, Mexico
| | | | - Jane O Schell
- Section of Palliative Care and Medical Ethics, Renal-Electrolyte Division, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jennifer S Scherer
- Department of Internal Medicine, NYU Grossman School of Medicine, New York, New York, USA
| | - Brendan Smyth
- Department of Renal Medicine, St George Hospital, Kogarah, Australia; School of Clinical Medicine, University of New South Wales, Kogarah, Australia; National Health and Medical Research Council (NHMRC) Clinical Trials Centre, University of Sydney, Camperdown, Australia
| | - Kaichiro Tamba
- Division of Palliative Care Medicine, Juchi Medical School University Hospital, Tochigi, Japan
| | - Nandini Vallath
- Department of Palliative Medicine, St Johns National Academy of Health Sciences, Bengaluru, India
| | - Nicola Wearne
- Division of Nephrology and Hypertension, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | | | - Carlos Zúñiga
- Facultad de Medicina, Universidad Católica de la Santísima Concepción, Concepción, Chile
| | - Frank P Brennan
- Kuratorium für Dialyse und Nierentransplantation, Neu-Isenburg, Germany; Department of Renal Medicine, St George Hospital, Kogarah, Australia
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Anderson E, Goins RT, Haozous EA, Schweinhart A. Testing a Culturally Tailored Advance Care Planning Intervention (MY WAY) for an American Indian Tribe: Protocol for a Quasi-Experimental Waitlist Control Design. JMIR Res Protoc 2023; 12:e50654. [PMID: 38157237 PMCID: PMC10787334 DOI: 10.2196/50654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 07/28/2023] [Accepted: 07/31/2023] [Indexed: 01/03/2024] Open
Abstract
BACKGROUND American Indian and Alaska Native peoples experience poor end-of-life care, including more hospitalizations and lower use of hospice and do-not-resuscitate orders. Although advance care planning (ACP) can improve end-of-life care, ACP rates are disproportionately low in American Indians and Alaska Natives. OBJECTIVE We culturally tailored and delivered an existing evidence-based ACP program for an American Indian tribal community. Here, we present the protocol for assessing the intervention's feasibility and efficacy. METHODS We measured feasibility via participant recruitment, participants' evaluation (acceptability, appropriateness, comprehension, and satisfaction), and intervention fidelity. Recruitment was measured with participant screening, eligibility, enrollment, and retention. Participant's evaluation of the intervention was measured with surveys. Fidelity was measured with direct observation and the Make Your Wishes About You (MY WAY) Fidelity Checklist Tool. To assess the intervention's efficacy, we used a quasi-experimental waitlist control design with 2 cohorts who were surveyed each on three separate occasions. The intervention's efficacy was assessed by the following: ACP barriers and facilitators as well as ACP self-efficacy, readiness, and completion. RESULTS A total of 166 participants were screened for eligibility; 11 were deemed ineligible, and 155 participants were enrolled in the study. Of those enrolled, 113 completed the intervention and will be included in subsequent analyses. We finalized data collection in January 2023, and analyses are underway. Study enrollment was successful, and we expect that participants will report high levels of acceptability, appropriateness, comprehension, and satisfaction with the intervention. We expect that the intervention was implemented with fidelity and will demonstrate decreases in ACP barriers and increases in ACP facilitators, self-efficacy, readiness, and completion. CONCLUSIONS Enrolling over twice as many participants as we had hoped suggests that members of this tribal community are willing to engage in end-of-life ACP. We were able to implement a waitlist study design to show that a culturally tailored ACP program for a tribal community is feasible. TRIAL REGISTRATION ClinicalTrials.gov NCT05304117; https://clinicaltrials.gov/study/NCT05304117. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/50654.
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Affiliation(s)
- Elizabeth Anderson
- Pacific Institute for Research and Evaluation, Chapel Hill, NC, United States
| | - R Turner Goins
- College of Health and Human Sciences, Western Carolina University, Cullowhee, NC, United States
| | - Emily A Haozous
- Pacific Institute for Research and Evaluation, Albuquerque, NM, United States
| | - April Schweinhart
- Pacific Institute for Research and Evaluatoin, Louisville, KY, United States
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Frandsen CE, Dieperink H, Trettin B, Agerskov H. Advance care planning to patients with chronic kidney disease and their families: An intervention development study. J Clin Nurs 2023; 32:8104-8115. [PMID: 37743635 DOI: 10.1111/jocn.16875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 08/16/2023] [Accepted: 08/21/2023] [Indexed: 09/26/2023]
Abstract
AIM To develop an advance care planning intervention based on the needs of patients with chronic kidney disease, families and healthcare professionals. BACKGROUND Patients with chronic kidney disease and their families request early advance care planning that continues throughout their illness trajectory. Healthcare professionals experience barriers to initiating advance care planning. Involvement of stakeholders in development of health interventions is important, to identify priorities, understand the problem and find solutions. METHOD The development was inspired by the Medical Research Council's framework, and codesign was applied. One future workshop and one design workshop were conducted with the consumers. The process was iterative, and data were analysed using the action research spiral. The Guidance for reporting intervention development studies in healthcare (GUIDED) was used. RESULTS Five areas were considered significant to an advance care planning intervention; a biopsychosocial approach, early palliative care, a family-focused approach, early and continuous advance care planning and a consumer-centred approach. Based on these, a conversation process with healthcare professionals was designed to give patients and families the opportunity to share values, preferences and wishes for treatment and their family and everyday life. CONCLUSION Codesign facilitated a collaborative process that allowed the consumers to have a significant impact on the design of an advance care planning intervention. A conversation process concerning everyday life, illness and treatment was designed for patients and families. The intervention included an advance care planning tool to guide the healthcare professionals. PRACTICE IMPLICATIONS The intervention has the intention to improve the communication between healthcare professionals, patients and families. The study provides important knowledge about the significance of giving the patients and their families support in sharing their values, preferences and wishes for treatment and everyday life, thus, to improve care and treatment in their illness trajectory. IMPACT What problem did the study address Patients with chronic kidney disease and their families strongly request early initiation of advance care planning that continues throughout the illness trajectory. Healthcare professionals experience barriers to the initiation of the advance care planning and request a more systematic approach. What were the main findings Development of a conversation process about everyday life, illness and treatment for patients diagnosed with chronic kidney disease and families, including an advance care planning tool to guide the healthcare professionals. Where and on whom will the research have an impact The study contributes an advance care planning intervention to patients in the early stages of chronic kidney disease and their families. We believe that the intervention could be included during consultations with healthcare professionals in other stages of chronic kidney disease as well as other chronic disease. REPORTING METHOD To strengthen the reporting of the development of the advance care planning intervention, we used the Guidance for reporting intervention development studies in healthcare (GUIDED). PATIENT OR PUBLIC CONTRIBUTION The development of the intervention in this study was a collaborative process between patients, families, healthcare professionals and representatives from the Danish Kidney Association, the department's user council and the research team.
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Affiliation(s)
- Christina Egmose Frandsen
- Department of Nephrology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Family Focused Healthcare Research Center (FaCe), Department of Clinical Research, University of Southern, Odense, Denmark
| | - Hans Dieperink
- Department of Nephrology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Bettina Trettin
- Department of Dermatology and Allergy Centre, Odense University Hospital, Odense, Denmark
| | - Hanne Agerskov
- Department of Nephrology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Family Focused Healthcare Research Center (FaCe), Department of Clinical Research, University of Southern, Odense, Denmark
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Frandsen CE, Dieperink H, Trettin B, Agerskov H. Advance care planning in chronic kidney disease: A national Danish survey of knowledge and attitudes among clinicians. Scand J Caring Sci 2023; 37:812-827. [PMID: 37069800 DOI: 10.1111/scs.13169] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 01/25/2023] [Accepted: 03/18/2023] [Indexed: 04/19/2023]
Abstract
INTRODUCTION Patients with chronic kidney disease and their families strongly request advance care planning. They want it to start early-before treatment decisions are made-and to be an ongoing process during their illness trajectory. Previous international studies show that health care professionals find there to be significant barriers that impact the extent of involvement in advance care planning. AIM To identify Danish nephrology health care professionals' knowledge and attitudes to advance care planning and the status of current advance care planning practice in Denmark. METHOD An anonymous, cross-sectional survey was administrated online. The questionnaire was developed in Australia and translated and culturally adapted into Danish. Health care professionals were recruited via email lists. In descriptive statistics and multiple ordinal regression, the influence of the respondents' attributes on the extent of involvement in advance care planning was explored, along with the involvement of family, and skills, comfort, barriers and facilitators in relation to advance care planning. RESULTS The 207 respondents comprised nephrologists (23%), other physicians (8%), nurses (62%) and other HCPs (7%), of whom 27% had participated in advance care planning training. In total, 66% indicated that they lacked access to material about advance care planning for patients with chronic kidney disease and 46% indicated that the conversations were performed ad hoc. A total of 47% reported that advance care planning was performed well at their workplace. Reported barriers were time, lack of experience and procedure. Training in advance care planning could facilitate the involvement. Nurses were less likely to feel skilled and comfortable in engaging advance care planning, while those with more than 10 years of experience were more likely to feel skilled and comfortable. CONCLUSION Training in advance care planning with patients with chronic kidney disease and their families on both a theoretical and clinical level is important to ensure comfort among health care professionals and to facilitate the extent of involvement. A systematic chronic kidney disease-specific approach is significant, in order to guide the conversations and ensure that advance care planning is conducted to a set standard.
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Affiliation(s)
- Christina Egmose Frandsen
- Department of Nephrology, Odense University Hospital, Odense C, Denmark
- Department of Clinical Research, Family Focused Healthcare Research Center (FaCe), University of Southern Denmark, Odense C, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense C, Denmark
- OPEN, Open Patient data Explorative Network, Odense University Hospital, Region of Southern Denmark, Odense C, Denmark
| | - Hans Dieperink
- Department of Nephrology, Odense University Hospital, Odense C, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense C, Denmark
| | - Bettina Trettin
- Department of Dermatology and Allergy Centre, Odense University Hospital, Odense C, Denmark
| | - Hanne Agerskov
- Department of Nephrology, Odense University Hospital, Odense C, Denmark
- Department of Clinical Research, Family Focused Healthcare Research Center (FaCe), University of Southern Denmark, Odense C, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense C, Denmark
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Testoni I, Ronconi L, Orkibi H, Biancalani G, Raccichini M, Franchini L, Keisari S, Bucuta M, Cieplinski K, Wieser M, Varani S. Death education for Palliative care: a european project for University students. BMC Palliat Care 2023; 22:47. [PMID: 37085886 PMCID: PMC10120108 DOI: 10.1186/s12904-023-01169-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 04/12/2023] [Indexed: 04/23/2023] Open
Abstract
BACKGROUND The need to spread the culture of palliative care and to train health care professionals from undergraduate courses is recognised internationally. The article presents the outcomes of a project devoted to palliative care training in university courses in four countries. AIMS This article considered the outcomes of a course designed for university students who had the potential to work in a palliative care team. The main aim was to check the efficacy of the course and the motivation to work in palliative care settings, considering the impact of fear and representations of death. METHODS The project presented the essential contents related to palliative care, using psychodramatic and photo-voice techniques. Longitudinal measurements were taken using a quantitative method design to detect changes among the students involved. The project involved 341 students at the first administration of the survey consisted of a protocol composed of standardized questionnaires in five countries (Austria, Israel, Italy, Poland and Romania), of whom 276 completed the pre- and post-surveys-165 of them in the experimental group and 111, in the control group. RESULTS The experience showed that it is possible to address death-related issues seriously and competently without necessarily causing discomfort and despondency in students. The results of the changes over time in the experimental and control groups highlight how the view of death as annihilation is correlated with the fear of death and the need for avoidance of thoughts concerning dying. The main result is that competence in palliative care facilitates familiarisation with issues of death and dying, as well as the ability to work in this area, thereby enhancing interpersonal skills. CONCLUSION The project showed that it is possible to implement death education on palliative care topics in undergraduate courses to increase motivation to work in this field.
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Grants
- 2019-1-IT02-KA203-063243 This research was funded by the Erasmus+Program of the European Union. Specifically, the funding for this study comes from the Erasmus plus project: "Death Education for Palliative Psychology" (DE4PP), project code: 2019-1-IT02-KA203-063243.
- 2019-1-IT02-KA203-063243 This research was funded by the Erasmus+Program of the European Union. Specifically, the funding for this study comes from the Erasmus plus project: "Death Education for Palliative Psychology" (DE4PP), project code: 2019-1-IT02-KA203-063243.
- 2019-1-IT02-KA203-063243 This research was funded by the Erasmus+Program of the European Union. Specifically, the funding for this study comes from the Erasmus plus project: "Death Education for Palliative Psychology" (DE4PP), project code: 2019-1-IT02-KA203-063243.
- 2019-1-IT02-KA203-063243 This research was funded by the Erasmus+Program of the European Union. Specifically, the funding for this study comes from the Erasmus plus project: "Death Education for Palliative Psychology" (DE4PP), project code: 2019-1-IT02-KA203-063243.
- 2019-1-IT02-KA203-063243 This research was funded by the Erasmus+Program of the European Union. Specifically, the funding for this study comes from the Erasmus plus project: "Death Education for Palliative Psychology" (DE4PP), project code: 2019-1-IT02-KA203-063243.
- 2019-1-IT02-KA203-063243 This research was funded by the Erasmus+Program of the European Union. Specifically, the funding for this study comes from the Erasmus plus project: "Death Education for Palliative Psychology" (DE4PP), project code: 2019-1-IT02-KA203-063243.
- 2019-1-IT02-KA203-063243 This research was funded by the Erasmus+Program of the European Union. Specifically, the funding for this study comes from the Erasmus plus project: "Death Education for Palliative Psychology" (DE4PP), project code: 2019-1-IT02-KA203-063243.
- 2019-1-IT02-KA203-063243 This research was funded by the Erasmus+Program of the European Union. Specifically, the funding for this study comes from the Erasmus plus project: "Death Education for Palliative Psychology" (DE4PP), project code: 2019-1-IT02-KA203-063243.
- 2019-1-IT02-KA203-063243 This research was funded by the Erasmus+Program of the European Union. Specifically, the funding for this study comes from the Erasmus plus project: "Death Education for Palliative Psychology" (DE4PP), project code: 2019-1-IT02-KA203-063243.
- 2019-1-IT02-KA203-063243 This research was funded by the Erasmus+Program of the European Union. Specifically, the funding for this study comes from the Erasmus plus project: "Death Education for Palliative Psychology" (DE4PP), project code: 2019-1-IT02-KA203-063243.
- 2019-1-IT02-KA203-063243 This research was funded by the Erasmus+Program of the European Union. Specifically, the funding for this study comes from the Erasmus plus project: "Death Education for Palliative Psychology" (DE4PP), project code: 2019-1-IT02-KA203-063243.
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Affiliation(s)
- Ines Testoni
- Department of Philosophy, Sociology, Education and Applied Psychology (FISPPA), University of Padova, Via Venezia 14, Padua, 35131, Italy.
- Drama & Health Science Lab, and the Emili Sagol Creative Arts Therapies Research Center, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israel.
| | - Lucia Ronconi
- IT and Statistical Services, Multifunctional Pole of Psychology, University of Padova, Padova, Italy
| | - Hod Orkibi
- Drama & Health Science Lab, and the Emili Sagol Creative Arts Therapies Research Center, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israel
| | - Gianmarco Biancalani
- Department of Philosophy, Sociology, Education and Applied Psychology (FISPPA), University of Padova, Via Venezia 14, Padua, 35131, Italy
| | | | | | - Shoshi Keisari
- Drama & Health Science Lab, and the Emili Sagol Creative Arts Therapies Research Center, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israel
| | - Mihaela Bucuta
- Department of Journalism, Public Relations, Sociology and Psychology, Lucian Blaga University of Sibiu, Sibiu, Romania
| | - Krzysztof Cieplinski
- Department of Psychotherapy and Health Psychology, The John Paul II Catholic University of Lublin, Lublin, Poland
| | - Michael Wieser
- Department of Psychology, Alpen-Adria-Universität Klagenfurt, Klagenfurt, Austria
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9
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Dempsey A, Mulder J. Quality Versus Quantity of Life: Beyond the Dichotomy. Palliat Med Rep 2023; 4:17-23. [PMID: 36743341 PMCID: PMC9892925 DOI: 10.1089/pmr.2022.0058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/12/2022] [Indexed: 01/20/2023] Open
Abstract
A restrictive and dichotomous question has become the primary approach in many goals of care discussions. Is the primary goal of care quantity of life through aggressive therapy or quality of life through comfort care and hospice? Even though many health care providers recognize that quality vs quantity of life (QvQ) is a false dichotomy, in practice QvQ underlies many goals of care discussions and can negatively impact patient care. This article offers strategies for assessing patients at the end of life, presenting a first-line conversation process that can support a range of treatment options as well as a diversity of dynamic patient values. Based on decades of experience in palliative care and a review of relevant literature, we recommend four practical questions to serve as values "vital signs," monitoring dynamic notions of quality of life and harmonizing patient values with treatment options.
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Affiliation(s)
- Ariel Dempsey
- Faculty of Theology and Religion, University of Oxford, Oxford, United Kingdom
| | - John Mulder
- Department of Family Medicine, Division of Palliative Medicine, Michigan State University College of Human Medicine, Grand Rapids, Michigan, USA; Trillium Institute, Spring Lake, Michigan, USA
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10
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Chen JHC, Lim WH, Howson P. Changing landscape of dialysis withdrawal in patients with kidney failure: Implications for clinical practice. Nephrology (Carlton) 2022; 27:551-565. [PMID: 35201646 PMCID: PMC9315017 DOI: 10.1111/nep.14032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Revised: 02/09/2022] [Accepted: 02/19/2022] [Indexed: 11/29/2022]
Abstract
Dialysis withdrawal has become an accepted treatment option for patients with kidney failure and is one of the leading causes of death in patients receiving dialysis in high-income countries. Despite its increasing acceptance, dialysis withdrawal currently lacks a clear, consistent definition. The processes and outcomes of dialysis withdrawal have wide temporal and geographical variability, attributed to dialysis patient selection, influence from cultural, religious and spiritual beliefs, and availability of kidney replacement therapy and conservative kidney management. As a complex, evolving process, dialysis withdrawal poses an enormous challenge for clinicians and healthcare teams with various limitations precluding a peaceful and smooth transition between active dialysis and end-of-life care. In this review, we examine the current definitions of dialysis withdrawal, the temporal and geographical patterns of dialysis withdrawal, international barriers in the decision-making process (including dialysis withdrawal during the COVID-19 pandemic), and gaps in the current dialysis withdrawal recommendations for clinical consideration and future studies.
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Affiliation(s)
- Jenny H C Chen
- Faculty of Medicine, University of Wollongong, Wollongong, Australia.,Wollongong Hospital, Wollongong, Australia
| | - Wai H Lim
- Department of Nephrology, Sir Charles Gairdner Hospital, Perth, Australia.,Faculty of Medicine, University of Western Australia, Perth, Australia
| | - Prue Howson
- Department of Nephrology, Sir Charles Gairdner Hospital, Perth, Australia
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11
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Guía de unidades de hemodiálisis 2020. Nefrologia 2021. [DOI: 10.1016/j.nefro.2021.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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12
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Frandsen CE, Dieperink H, Detering K, Agerskov H. Patients' with chronic kidney disease and their relatives' perspectives on advance care planning: A meta-ethnography. J Ren Care 2021; 48:154-167. [PMID: 34619019 DOI: 10.1111/jorc.12399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 08/18/2021] [Accepted: 09/08/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Advance care planning is a process that supports adults of any age and stage of illness in understanding and sharing their values, life goals, and preferences regarding medical care. Chronic kidney disease is a progressive and lifelong disease. Close relatives often represent patients' most important support. Advance care planning is recommended to be a continuous part of a person's ongoing treatment and is not solely related to end-of-life care. However, no studies have focused on advanced care planning for patients with chronic kidney disease earlier than the onset of a terminal illness. AIM The aim is to describe experiences of and perspectives on advance care planning among patients with chronic kidney disease and their close relatives. METHODS We conducted a meta-ethnography of studies that used individual, dyad, and focus group interviews. We searched five electronic databases: PubMed, Cinahl, Embase, PsycINFO, and Scopus and reference lists of relevant articles. RESULTS Seven articles were included. Participants had a need for advance care planning to make shared decisions about treatment and everyday life. The responsibility for initiating advance care planning lay with the healthcare professionals. Differences between advance care planning goals among patients, relatives, and healthcare professionals complicated the advance care planning process. A focus on day-to-day care at the expense of focusing on advance care planning gave an impression of a lack of competencies and interest. For some patients, the involvement of relatives was of significant value; however, it could be associated with burden and pressure. CONCLUSION Patients with chronic kidney disease and their families have a need for early advance care planning before dialysis or transplantation is initiated, so as to facilitate shared decision-making related to treatment options and everyday life. It is important that patients, their relatives, and healthcare professionals share the same advance care planning goals, to get sufficient discussions and thus, achieve clarity about prognosis, medical care, and the illness trajectory.
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Affiliation(s)
- Christina E Frandsen
- Department of Nephrology, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, Family Focused Healthcare Research Center (FaCe), University of Southern Denmark, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Hans Dieperink
- Department of Nephrology, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, Family Focused Healthcare Research Center (FaCe), University of Southern Denmark, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Karen Detering
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark.,Department of Health Professions, Faculty of Health, Art and Innovation, Swinburne University of Technology, Melbourne, Australia.,Launceston General Hospital, Tasmanian Health Services, Launceston, Tasmania, Australia
| | - Hanne Agerskov
- Department of Nephrology, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, Family Focused Healthcare Research Center (FaCe), University of Southern Denmark, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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13
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Butler CR, Vig EK, O'Hare AM, Liu CF, Hebert PL, Wong SPY. Ethical Concerns in the Care of Patients with Advanced Kidney Disease: a National Retrospective Study, 2000-2011. J Gen Intern Med 2020; 35:1035-1043. [PMID: 31654358 PMCID: PMC7174459 DOI: 10.1007/s11606-019-05466-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 07/26/2019] [Accepted: 09/19/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND Understanding ethical concerns that arise in the care of patients with advanced kidney disease may help identify opportunities to support medical decision-making. OBJECTIVE To describe the clinical contexts and types of ethical concerns that arise in the care of patients with advanced kidney disease. DESIGN Retrospective cohort study. PARTICIPANTS A total of 28,568 Veterans with advanced kidney disease between 2000 and 2009 followed through death or 2011. EXPOSURE Clinical scenarios that prompted clinicians to consider an ethics consultation as documented in the medical record. MAIN MEASURES Dialysis initiation, dialysis discontinuation, receipt of an intensive procedure during the final month of life, and hospice enrollment. KEY RESULTS Patients had a mean age of 67.1 years, and the majority were male (98.5%) and white (59.0%). Clinicians considered an ethics consultation for 794 patients (2.5%) over a median follow-up period of 2.7 years. Ethical concerns involved code status (37.8%), dialysis (54.5%), other invasive treatments (40.6%), and noninvasive treatments (61.1%) and were related to conflicts between patients, their surrogates, and/or clinicians about treatment preferences (79.3%), who had authority to make healthcare decisions (65.9%), and meeting the care needs of patients versus obligations to others (10.6%). Among the 20,583 patients who died during follow-up, those for whom clinicians had considered an ethics consultation were less likely to have been treated with dialysis (47.6% versus 62.0%, adjusted odds ratio [aOR] 0.63, 95% CI 0.53-0.74), more likely to have discontinued dialysis (32.5% versus 20.9%, aOR 2.07, CI 1.61-2.66), and less likely to have received an intensive procedure in the last month of life (8.9% versus 18.9%, aOR 0.41, CI 0.32-0.54) compared with patients without documentation of clinicians having considered consultation. CONCLUSIONS Clinicians considered an ethics consultation for patients with advanced kidney disease in situations of conflicting preferences regarding dialysis and other intensive treatments, especially when these treatments were not pursued.
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Affiliation(s)
- Catherine R Butler
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA, USA.
| | - Elizabeth K Vig
- Geriatrics and Extended Care, VA Puget Sound Healthcare System, Seattle, WA, USA.,Division of Gerontology and Geriatric Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Ann M O'Hare
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA, USA.,Health Service Research and Development Center of Innovation, VA Puget Sound Healthcare System, Seattle, WA, USA
| | - Chuan-Fen Liu
- Health Service Research and Development Center of Innovation, VA Puget Sound Healthcare System, Seattle, WA, USA.,Department of Health Services, University of Washington, Seattle, WA, USA
| | - Paul L Hebert
- Health Service Research and Development Center of Innovation, VA Puget Sound Healthcare System, Seattle, WA, USA.,Department of Health Services, University of Washington, Seattle, WA, USA
| | - Susan P Y Wong
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA, USA.,Health Service Research and Development Center of Innovation, VA Puget Sound Healthcare System, Seattle, WA, USA
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14
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Oskoui T, Pandya R, Weiner DE, Wong JB, Koch-Weser S, Ladin K. Advance Care Planning Among Older Adults With Advanced Non-Dialysis-Dependent CKD and Their Care Partners: Perceptions Versus Reality? Kidney Med 2020; 2:116-124. [PMID: 32734232 PMCID: PMC7384367 DOI: 10.1016/j.xkme.2019.11.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Rationale & Objective Older patients with advanced chronic kidney disease (CKD) use intensive care at the end of life and die in a hospital more frequently than patients with cancer or heart disease. Advance care planning (ACP) can help align treatment with patient preferences and improve patient-centered care, yet ACP quality and experiences among older patients with CKD and their care partners remain incompletely understood, particularly among the non–dialysis-dependent population. Study Design In-person interviewer-administered surveys of patients 70 years and older with non–dialysis-dependent CKD stage 4 or 5 and their self-identified care partners. Setting & Participants 42 participants (31 patients, 11 care partners) at 2 clinical sites in greater Boston. Outcomes Completion of advance directives and self-reported perceptions, preferences, and experiences of ACP. Analytical Approach Descriptive analysis of patient and care partner surveys. McNemar test analysis to compare patient and care partner responses. Results Most patients had written advance directives (64%) and surrogate decision makers (81%). Although patients reported positive perceptions and high trust in their clinicians’ judgment, few (16%) had actually discussed preferences for life-sustaining treatment with their nephrologists. Few ACP discussions included components reflective of high-quality ACP: 16% of patients had been asked about their values concerning end-of-life care and 7% had discussed issues of decision-making capacity and consent to care should their health decline. When presented with 2 hypothetical scenarios (stroke/heart attack or dementia), nearly all patients and care partners reported a preference for comfort care over delaying death. Care partners were more likely than patients to report that they had experienced discussion components reflective of high-quality ACP with the clinical team. Limitations Single metropolitan area; most patients did not identify a care partner; nonresponse bias and small sample size. Conclusions Patients often believed that their clinicians understood their end-of-life wishes despite not having engaged in ACP conversations that would make those wishes known. Improving clinical ACP communication may result in end-of-life treatment that better aligns with patient goals.
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Affiliation(s)
- Tira Oskoui
- Research on Ethics, Aging, and Community Health (REACH Lab), Boston, MA
| | - Renuka Pandya
- Research on Ethics, Aging, and Community Health (REACH Lab), Boston, MA
| | - Daniel E Weiner
- Department of Medicine, Tufts Medical Center, Boston, MA.,William B Schwartz MD Division of Nephrology, Tufts Medical Center, Boston, MA
| | - John B Wong
- Department of Medicine, Tufts Medical Center, Boston, MA
| | - Susan Koch-Weser
- Department of Public Health & Community Medicine, Tufts University School of Medicine, Boston, MA
| | - Keren Ladin
- Research on Ethics, Aging, and Community Health (REACH Lab), Boston, MA.,Department of Occupational Therapy, Tufts University, Medford, MA.,Department of Community Health, Tufts University, Medford, MA
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15
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Advance care planning with patients on hemodialysis: an implementation study. BMC Palliat Care 2019; 18:64. [PMID: 31349844 PMCID: PMC6659207 DOI: 10.1186/s12904-019-0437-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Accepted: 06/21/2019] [Indexed: 11/10/2022] Open
Abstract
Background Patients with end-stage kidney disease (ESKD) on hemodialysis have limited life expectancy, yet their palliative care needs often go unmet. The aim of this study was to identify barriers and facilitators for implementation of “Shared Decision Making and Renal Supportive Care” (SDM-RSC), an intervention to improve advance care planning (ACP) for patients with ESKD on hemodialysis. Methods The Consolidated Framework for Implementation Research (CFIR) was the organizing framework for this study. CFIR is a theory-based implementation framework consisting of five domains (Intervention Characteristics, Inner Setting, Outer Setting, Characteristics of Individuals, and Process), each of which has associated constructs. Potential barriers and facilitators to implementation of the SDM-RSC intervention were identified through observation of study procedures, surveys of social workers nephrologists, study participants, and family members, and assessment of intervention fidelity. Results Twenty-nine nephrologists and 24 social workers, representing 18 outpatient dialysis units in Massachusetts (n = 10) and New Mexico (n = 8), were trained to conduct SDM-RSC intervention sessions. A total of 102 of 125 patient enrolled in the study received the intervention; 40 had family members present. Potential barriers and facilitators to implementation of the SDM-RSC intervention were identified in each of the five CFIR domains. Barriers included complexity of the intervention; challenges to meeting with patients on non-dialysis days; difficulties scheduling intervention sessions due to nephrologists’ and social workers’ caseloads; perceived need for local policy change regarding ACP; perceived need for additional ACP training for social workers and nephrologists; and lack of endorsement of the intervention by some staff members. Facilitators included: training for social workers, national dialysis chain leadership engagement and the institution of social worker/nephrologist clinic champions. Conclusions ACP for patients on hemodialysis can have a positive impact on end-of-life outcomes for patients and their families but does not take place routinely. The barriers to effective implementation of interventions to improve ACP identified in this study might be addressed by: adapting the intervention for local contexts with input from clinicians, dialysis staff, patients and families; providing nephrologists and social workers additional training prior to delivering the intervention; and developing policy that routinizes ACP for hemodialysis patients. Trial registration Clinicaltrials.gov NCT02405312. Registered 04/01/2015. Electronic supplementary material The online version of this article (10.1186/s12904-019-0437-2) contains supplementary material, which is available to authorized users.
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16
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Fahner JC, Beunders AJ, van der Heide A, Rietjens JA, Vanderschuren MM, van Delden JJ, Kars MC. Interventions Guiding Advance Care Planning Conversations: A Systematic Review. J Am Med Dir Assoc 2019; 20:227-248. [DOI: 10.1016/j.jamda.2018.09.014] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Revised: 09/11/2018] [Accepted: 09/18/2018] [Indexed: 12/14/2022]
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17
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Davison SN. Integrating Palliative Care for Patients with Advanced Chronic Kidney Disease: Recent Advances, Remaining Challenges. J Palliat Care 2018. [DOI: 10.1177/082585971102700109] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Sara N. Davison
- Department of Medicine and Institute of Health Economics, University of Alberta, 11–107 Clinical Sciences Building, Edmonton, Alberta, Canada T6G 2G3
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18
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Winterbottom AE, Bekker HL, Russon L, Hipkiss V, Ziegler L, Williams R, Mooney A. Dialysis vs conservative management decision aid: a study protocol. ACTA ACUST UNITED AC 2018. [DOI: 10.12968/jokc.2018.3.3.179] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Anna E Winterbottom
- Research Psychologist, Adult Renal Services, Lincoln Wing, St James's University Hospital, Leeds
| | - Hilary L Bekker
- Professor of Medical Decision Making, Leeds Institute of Health Sciences, University of Leeds, Leeds
| | - Lynne Russon
- Consultant, Palliative Medicine. Leeds Teaching Hospitals Trust and Sue Ryder Care, Wheatfields Hospice, Leeds
| | - Vicki Hipkiss
- Senior Sister, St Luke's Hospital, Bradford, West Yorkshire
| | - Lucy Ziegler
- Yorkshire Cancer Research Academic Fellow, Academic Unit of Palliative Care, Leeds Institute of Health Sciences, University of Leeds, Leeds
| | | | - Andrew Mooney
- Consultant Renal Physician. Adult Renal Services, St James's University Hospital, Leeds
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19
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Ladin K, Pandya R, Kannam A, Loke R, Oskoui T, Perrone RD, Meyer KB, Weiner DE, Wong JB. Discussing Conservative Management With Older Patients With CKD: An Interview Study of Nephrologists. Am J Kidney Dis 2018; 71:627-635. [PMID: 29396240 PMCID: PMC5916578 DOI: 10.1053/j.ajkd.2017.11.011] [Citation(s) in RCA: 76] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 11/06/2017] [Indexed: 11/11/2022]
Abstract
BACKGROUND Although dialysis may not provide a large survival benefit for older patients with kidney failure, few are informed about conservative management. Barriers and facilitators to discussions about conservative management and nephrologists' decisions to present the option of conservative management may vary within the nephrology provider community. STUDY DESIGN Interview study of nephrologists. SETTING & PARTICIPANTS National sample of US nephrologists sampled based on sex, years in practice, practice type, and region. METHODOLOGY Qualitative semistructured interviews continued until thematic saturation. ANALYTICAL APPROACH Thematic and narrative analysis of recorded and transcribed interviews. RESULTS Among 35 semistructured interviews with nephrologists from 18 practices, 37% described routinely discussing conservative management ("early adopters"). 5 themes and related subthemes reflected issues that influence nephrologists' decisions to discuss conservative management and their approaches to these discussions: struggling to define nephrologists' roles (determining treatment, instilling hope, and improving patient symptoms), circumventing end-of-life conversations (contending with prognostic uncertainty, fearing emotional backlash, jeopardizing relationships, and tailoring information), confronting institutional barriers (time constraints, care coordination, incentives for dialysis, and discomfort with varied conservative management approaches), conservative management as "no care," and moral distress. Nephrologists' approaches to conservative management discussions were shaped by perceptions of their roles and by a common view of conservative management as no care. Their willingness to pursue conservative management was influenced by provider- and institutional-level barriers and experiences with older patients who regretted or had been harmed by dialysis (moral distress). Early adopters routinely discussed conservative management as a way of relieving moral distress, whereas others who were more selective in discussing conservative management experienced greater distress. LIMITATIONS Participants' views are likely most transferable to large academic medical centers, due to oversampling of academic clinicians. CONCLUSIONS Our findings clarify how moral distress serves as a catalyst for conservative management discussion and highlight points of intervention and mechanisms potentially underlying low conservative management use in the United States.
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Affiliation(s)
- Keren Ladin
- Department of Occupational Therapy, Tufts University, Medford, MA; Research on Aging, Ethics, and Community Health, Tufts University, Medford, MA.
| | - Renuka Pandya
- Research on Aging, Ethics, and Community Health, Tufts University, Medford, MA
| | - Allison Kannam
- Research on Aging, Ethics, and Community Health, Tufts University, Medford, MA
| | - Rohini Loke
- Research on Aging, Ethics, and Community Health, Tufts University, Medford, MA
| | - Tira Oskoui
- Research on Aging, Ethics, and Community Health, Tufts University, Medford, MA
| | | | | | | | - John B Wong
- Department of Medicine, Tufts Medical Center, Boston, MA
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20
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Werdecker L, Kujawa M, Schneider N, Neitzke G. [Advance care planning: A qualitative investigation on patients' perspectives with advanced heart failure]. Z Gerontol Geriatr 2018; 52:157-163. [PMID: 29671084 DOI: 10.1007/s00391-018-1385-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Revised: 02/27/2018] [Accepted: 03/09/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND The Hospice and Palliative Care Act (2015) promotes advance care planning (ACP) for patients in nursing homes, but chronically ill patients living at home can also benefit from ACP. OBJECTIVE The aim of the study was to analyze the perception of ACP consultations by patients with advanced heart failure. MATERIAL AND METHODS Patients (70 years and older) with advanced heart failure participated in two physician-led ACP consultations. Afterwards, two evaluative interviews were conducted with each participant. All consultations and interviews were analyzed by grounded theory considering the coding paradigm. Finally, an empirical grounded typology was conducted. RESULTS A total of 30 patients participated in at least 1 ACP consultation, whereas 18 persons completed an interview. Successful ACP consultations depend not only on the discussion but also on the patient's requirements: willingness to discuss ACP, their illness, death and dying, and the experienced and preferred role in healthcare decision-making. From the patient's viewpoint ACP consultation can result in an advance directive, but an informed rejection of ACP or the creation of new assumptions for the future are also possible outcomes. CONCLUSION The ACP discussions should to be aligned to patients' preferences in terms of communication and content. It is important to accept a rejection of dealing with ACP or conducting an advance directive. The patients' view needs to be integrated into future research.
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Affiliation(s)
- Lena Werdecker
- Institut für Geschichte, Ethik und Philosophie der Medizin, Medizinische Hochschule Hannover, Hannover, Deutschland. .,Fakultät für Gesundheit, Institut für Integrative Gesundheitsversorgung und Gesundheitsförderung, Universität Witten/Herdecke, Alfred-Herrhausen-Straße 50, Witten, 58448, Deutschland.
| | - Matthias Kujawa
- Institut für Geschichte, Ethik und Philosophie der Medizin, Medizinische Hochschule Hannover, Hannover, Deutschland
| | - Nils Schneider
- Institut für Allgemeinmedizin, Medizinische Hochschule Hannover, Hannover, Deutschland
| | - Gerald Neitzke
- Institut für Geschichte, Ethik und Philosophie der Medizin, Medizinische Hochschule Hannover, Hannover, Deutschland
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21
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Sas C. Advance Care Planning for Patients with End-Stage Renal Disease. HEALTH & SOCIAL WORK 2018; 43:63-66. [PMID: 29253119 DOI: 10.1093/hsw/hlx050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Accepted: 03/17/2017] [Indexed: 06/07/2023]
Affiliation(s)
- Courtney Sas
- Courtney Sas, MSW, RSW, is a social worker, St. Michael's Hospital, 30 Bond Street, Toronto, ON M5B 1X1, Canada; e-mail:
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Abstract
Patients with chronic kidney disease typically suffer a cascade of comorbid conditions, the magnitude of which have formidable impact on advance care planning (ACP). Complex health care decisions are complicated further by contextual issues that may change over time. A dynamic and evolving process, ACP ideally begins early in the continuum of chronic kidney disease, long before end-stage kidney disease is reached. Planning ahead for care is preparatory to making decisions about kidney replacement therapy and can make for a smooth transition in addition to preventing the start of dialysis by default. This article addresses the key components and unique aspects of ACP for patients approaching dialysis, highlighting the importance of shared decision making, and its effect on the execution of multiple aspects of transition.
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23
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Llewellyn R, Jaye C, Egan R, Cunningham W, Young J, Radue P. Living into death: a case for an iterative, fortified and cross-sector approach to advance care planning. Anthropol Med 2017; 24:350-365. [PMID: 28506127 DOI: 10.1080/13648470.2017.1285000] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Advance care planning (ACP) has been framed as best practice for quality palliative care, yet a growing body of literature affirms the need for an early iterative ACP process to begin when people are young and healthy. A significant gap appears to exist in the literature regarding the utility of death conversations outside the end-of-life context. Could 'death conversations' early in life be an effective tool by which doctor and patient can co-construct a more healthful way of life, and realistic relationship with death? And what variables must be taken into account for these conversations to proceed successfully? This paper provides a narrative exploration of the value of death conversations in the clinical context in New Zealand. Five exemplars are discussed, drawn from a sample of 21 semi-structured interviews with young older adults (54-65 years old) not receiving palliative care or diagnosed with a terminal illness. Together, these narratives indicate that further community consultation is required to determine culturally appropriate ways to initiate productive conversations around aging, death and dying and how to build patient/practitioner/family relationships which allow these conversations to happen safely. There is a need to acknowledge the important factor of culture related to age, generation, sex, faith and ethnicity when engaging in conversations about aging, death and dying. By doing so, health professionals will be best equipped to assist their patients to live well into death.
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Affiliation(s)
- Rebecca Llewellyn
- a Department of Preventive and Social Medicine , University of Otago , Dunedin , New Zealand
| | - Chrystal Jaye
- b Department of General Practice and Rural Health , University of Otago , Dunedin , New Zealand
| | - Richard Egan
- a Department of Preventive and Social Medicine , University of Otago , Dunedin , New Zealand
| | - Wayne Cunningham
- c Royal College of Surgeons in Ireland , Medical University of Bahrain , Adilya , Bahrain
| | - Jessica Young
- b Department of General Practice and Rural Health , University of Otago , Dunedin , New Zealand
| | - Peter Radue
- b Department of General Practice and Rural Health , University of Otago , Dunedin , New Zealand
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Lazenby S, Edwards A, Samuriwo R, Riley S, Murray MA, Carson‐Stevens A. End-of-life care decisions for haemodialysis patients - 'We only tend to have that discussion with them when they start deteriorating'. Health Expect 2017; 20:260-273. [PMID: 26968338 PMCID: PMC5354044 DOI: 10.1111/hex.12454] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/10/2016] [Indexed: 01/28/2023] Open
Abstract
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.
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Affiliation(s)
- Sophia Lazenby
- Primary Care Patient Safety (PISA) Research GroupDivision of Population MedicineSchool of MedicineCardiff UniversityCardiffWalesUK
| | - Adrian Edwards
- Division of Population MedicineSchool of MedicineCardiff UniversityCardiffWalesUK
- Primary and Emergency Care Research (PRIME) Centre WalesCardiff UniversityCardiffWalesUK
| | - Raymond Samuriwo
- School of Healthcare SciencesCardiff UniversityCardiffWalesUK
- Cardiff Institute for Tissue Engineering and RepairCardiff UniversityCardiffWalesUK
- School of HealthcareUniversity of LeedsLeedsUK
| | | | - Mary Ann Murray
- Nursing Palliative Research and Education UnitFaculty of Health SciencesUniversity of OttawaOttawaONCanada
| | - Andrew Carson‐Stevens
- Primary and Emergency Care Research (PRIME) Centre WalesCardiff UniversityCardiffWalesUK
- Department of Family PracticeUniversity of British ColumbiaVancouverBCCanada
- Institute of Healthcare Policy and PracticeUniversity of the West of ScotlandPaisleyScotland
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Carson RC, Bernacki R. Is the End in Sight for the "Don't Ask, Don't Tell" Approach to Advance Care Planning? Clin J Am Soc Nephrol 2017; 12:380-381. [PMID: 28232404 PMCID: PMC5338698 DOI: 10.2215/cjn.00980117] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Rachel C Carson
- Island Health, Nanaimo Regional Hospital, Nanaimo, British Columbia, Canada; and
| | - Rachelle Bernacki
- Division of Adult Palliative Care, Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute and Ariadne Labs, Brigham and Women's Hospital & Harvard School of Public Health, Boston, Massachusetts
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Luckett T, Spencer L, Morton RL, Pollock CA, Lam L, Silvester W, Sellars M, Detering KM, Butow PN, Tong A, Clayton JM. Advance care planning in chronic kidney disease: A survey of current practice in Australia. Nephrology (Carlton) 2017; 22:139-149. [DOI: 10.1111/nep.12743] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Revised: 02/03/2016] [Accepted: 02/05/2016] [Indexed: 02/05/2023]
Affiliation(s)
- Tim Luckett
- Improving Palliative Care through Clinical Trials (ImPaCCT) New South Wales; New South Wales Australia
- Faculty of Health; University of Technology Sydney (UTS); Sydney New South Wales Australia
| | - Lucy Spencer
- Department of Renal Medicine; Royal North Shore Hospital; Sydney New South Wales Australia
| | - Rachael L Morton
- NHMRC Clinical Trials Centre; The University of Sydney; Sydney New South Wales Australia
| | - Carol A Pollock
- Department of Renal Medicine; Royal North Shore Hospital; Sydney New South Wales Australia
- Sydney Medical School; The University of Sydney; Sydney New South Wales Australia
| | - Lawrence Lam
- Faculty of Health; University of Technology Sydney (UTS); Sydney New South Wales Australia
| | - William Silvester
- Respecting Patient Choices; Austin Health; Melbourne Victoria Australia
| | - Marcus Sellars
- Sydney Medical School; The University of Sydney; Sydney New South Wales Australia
- Respecting Patient Choices; Austin Health; Melbourne Victoria Australia
| | - Karen M Detering
- Respecting Patient Choices; Austin Health; Melbourne Victoria Australia
| | - Phyllis N Butow
- School of Psychology; The University of Sydney; Sydney New South Wales Australia
| | - Allison Tong
- School of Public Health; The University of Sydney; Sydney New South Wales Australia
| | - Josephine M Clayton
- Improving Palliative Care through Clinical Trials (ImPaCCT) New South Wales; New South Wales Australia
- Sydney Medical School; The University of Sydney; Sydney New South Wales Australia
- HammondCare Palliative & Supportive Care Service; Greenwich Hospital; Sydney New South Wales
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Yuen SK, Suen HP, Kwok OL, Yong SP, Tse MW. Advance care planning for 600 Chinese patients with end-stage renal disease. ACTA ACUST UNITED AC 2016. [DOI: 10.1016/j.hkjn.2016.04.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Lim CED, Ng RWC, Cheng NCL, Cigolini M, Kwok C, Brennan F. Advance care planning for haemodialysis patients. Cochrane Database Syst Rev 2016; 7:CD010737. [PMID: 27457661 PMCID: PMC6458029 DOI: 10.1002/14651858.cd010737.pub2] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND End-stage kidney disease (ESKD) is a chronic, debilitative and progressive illness that may need interventions such as dialysis, transplantation, dietary and fluid restrictions. Most patients with ESKD will require renal replacement therapy, such as kidney transplantation or maintenance dialysis. Advance care planning traditionally encompass instructions via living wills, and concern patient preferences about interventions such as cardiopulmonary resuscitation and feeding tubes, or circumstances around assigning surrogate decision makers. Most people undergoing haemodialysis are not aware of advance care planning and few patients formalise their wishes as advance directives and of those who do, many do not discuss their decisions with a physician. Advance care planning involves planning for future healthcare decisions and preferences of the patient in advance while comprehension is intact. It is an essential part of good palliative care that likely improves the lives and deaths of haemodialysis patients. OBJECTIVES The objective of this review was to determine whether advance care planning in haemodialysis patients, compared with no or less structured forms of advance care planning, can result in fewer hospital admissions or less use of treatments with life-prolonging or curative intent, and if patient's wishes were followed at end-of-life. SEARCH METHODS We searched the Cochrane Kidney and Transplant Specialised Register to 27 June 2016 through contact with the Information Specialist using search terms relevant to this review. We also searched the Cumulative Index of Nursing and Allied Health Literature (CINAHL), and Social Work Abstracts (OvidSP). SELECTION CRITERIA All randomised controlled trials (RCTs) and quasi-RCTs (RCTs in which allocation to treatment was obtained by alternation, use of alternate medical records, date of birth or other predictable methods) looking at advance care planning versus no form of advance care planning in haemodialysis patients was considered for inclusion without language restriction. DATA COLLECTION AND ANALYSIS Data extraction was carried out independently by two authors using standard data extraction forms. Studies reported in non-English language journals were translated before assessment. Where more than one publication of one study exists, reports were grouped together and the publication with the most complete data was used in the analyses. Where relevant outcomes are only published in earlier versions these data were used. Any discrepancies between published versions were highlighted. Non-randomised controlled studies were excluded. MAIN RESULTS We included two studies (three reports) that involved 337 participants which investigated advance care planning for people with ESKD. Neither of the included studies reported outcomes relevant to this review. Study quality was assessed as suboptimal. AUTHORS' CONCLUSIONS We found sparse data that were assessed at suboptimal quality and therefore we were unable to formulate conclusions about whether advance care planning can influence numbers of hospital admissions and treatment required by people with ESKD, or if patients' advance care directives were followed at end-of-life. Further well designed and adequately powered RCTs are needed to better inform patient and clinical decision-making about advance care planning and advance directives among people with ESKD who are undergoing dialysis.
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Affiliation(s)
- Chi Eung Danforn Lim
- University of Technology SydneyFaculty of ScienceC/O Earlwood Medical Centre,356 Homer StreetEarlwoodNew South WalesAustralia2206
| | - Rachel WC Ng
- University of New South WalesFaculty of MedicineHurstvilleNSWAustralia2220
| | - Nga Chong Lisa Cheng
- University of New South WalesSouth Western Sydney Clinical School, Faculty of MedicinePO Box 3256BlakehurstNSWAustralia2221
| | - Maria Cigolini
- Royal Prince Alfred HospitalDepartment of Palliative MedicineCamperdownNSWAustralia2050
| | - Cannas Kwok
- University of Western SydneySchool of Nursing and MidwiferyBuilding EB/LG Room 51Parramatta South CompusParramattaNSWAustralia2145
| | - Frank Brennan
- St George HospitalDepartment of Renal MedicineKogarahNSWAustralia2217
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Saini G, Sampson EL, Davis S, Kupeli N, Harrington J, Leavey G, Nazareth I, Jones L, Moore KJ. An ethnographic study of strategies to support discussions with family members on end-of-life care for people with advanced dementia in nursing homes. BMC Palliat Care 2016; 15:55. [PMID: 27388766 PMCID: PMC4936120 DOI: 10.1186/s12904-016-0127-2] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Accepted: 06/28/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Most people with advanced dementia die in nursing homes where families may have to make decisions as death approaches. Discussions about end-of-life care between families and nursing home staff are uncommon, despite a range of potential benefits. In this study we aimed to examine practices relating to end-of-life discussions with family members of people with advanced dementia residing in nursing homes and to explore strategies for improving practice. METHODS An ethnographic study in two nursing homes where the Compassion Intervention was delivered. The Compassion Intervention provides a model of end-of-life care engaging an Interdisciplinary Care Leader to promote integrated care, educate staff, support holistic assessments and discuss end of life with families. We used a framework approach, undertaking a thematic analysis of fieldwork notes and observations recorded in a reflective diary kept by the Interdisciplinary Care Leader, and data from in-depth interviews with 23 informants: family members, GPs, nursing home staff, and external healthcare professionals. RESULTS Four major themes described strategies for improving practice: (i) educating families and staff about dementia progression and end-of-life care; (ii) appreciating the greater value of in-depth end-of-life discussions compared with simple documentation of care preferences; (iii) providing time and space for sensitive discussions; and (iv) having an independent healthcare professional or team with responsibility for end-of-life discussions. CONCLUSIONS The Interdisciplinary Care Leader role offers a promising method for supporting and improving end-of-life care discussions between families of people with advanced dementia and nursing home staff. These strategies warrant further evaluation in nursing home settings.
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Affiliation(s)
- Geena Saini
- Centre for Mental Health, Maya House, 134-138 Borough High Street, London, SE1 1LB, UK
| | - Elizabeth L Sampson
- Marie Curie Palliative Care Research Department (MCPCRD), Division of Psychiatry, University College London, 6th Floor, Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK
| | - Sarah Davis
- Marie Curie Palliative Care Research Department (MCPCRD), Division of Psychiatry, University College London, 6th Floor, Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK
| | - Nuriye Kupeli
- Marie Curie Palliative Care Research Department (MCPCRD), Division of Psychiatry, University College London, 6th Floor, Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK
| | - Jane Harrington
- Marie Curie Palliative Care Research Department (MCPCRD), Division of Psychiatry, University College London, 6th Floor, Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK
| | - Gerard Leavey
- Bamford Centre for Mental Health & Wellbeing, University of Ulster, Magee Campus, Northland Road, Derry Londonderry, BT48 7JL, UK
| | - Irwin Nazareth
- Department of Primary Care and Population Health, UCL Royal Free Site, Rowland Hill Street, London, NW3, UK
| | - Louise Jones
- Marie Curie Palliative Care Research Department (MCPCRD), Division of Psychiatry, University College London, 6th Floor, Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK
| | - Kirsten J Moore
- Marie Curie Palliative Care Research Department (MCPCRD), Division of Psychiatry, University College London, 6th Floor, Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK.
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Effiong A, Shinn L, Pope TM, Raho JA. Advance care planning for end-stage kidney disease. Hippokratia 2016. [DOI: 10.1002/14651858.cd010687.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Andem Effiong
- United States Department of Health and Human Services; 10903 New Hampshire Avenue Silver Spring Maryland USA 20993
- Georgetown University School of Medicine; Washington DC USA
- Union Graduate College - Icahn School of Medicine at Mount Sinai; Mount Sinai New York USA
| | - Laura Shinn
- Rowan University; Political Science and Economics; Glassboro New Jersey USA
| | - Thaddeus M Pope
- Hamline University School of Law; Health Law Institute; MS-D2017 1536 Hewitt Ave Saint Paul Minnesota USA 55104-1237
| | - Joseph A Raho
- Universita di Pisa; Department of Philosophy; Visa Fabio Filzi, 35 Pisa Italy 56123
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Cohen RA, Jackson VA, Norwich D, Schell JO, Schaefer K, Ship AN, Sullivan AM. A Nephrology Fellows' Communication Skills Course: An Educational Quality Improvement Report. Am J Kidney Dis 2016; 68:203-211. [PMID: 26994686 DOI: 10.1053/j.ajkd.2016.01.025] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Accepted: 01/24/2016] [Indexed: 11/11/2022]
Abstract
BACKGROUND Nephrology fellows need expertise navigating challenging conversations with patients throughout the course of advanced kidney disease. However, evidence shows that nephrologists receive inadequate training in this area. This study assessed the effectiveness of an educational quality improvement intervention designed to enhance fellows' communication with patients who have advanced kidney disease. STUDY DESIGN Quality improvement project. SETTING & PARTICIPANTS Full-day annual workshops (2013-2014) using didactics, discussion, and practice with simulated patients. Content focused on delivering bad news, acknowledging emotion, discussing care goals in dialysis decision making when prognosis is uncertain, and addressing dialysis therapy withdrawal and end of life. Participants were first-year nephrology fellows from 2 Harvard-affiliated training programs (N=26). QUALITY IMPROVEMENT PLAN Study assessed the effectiveness of an intervention designed to enhance fellows' communication skills. OUTCOMES Primary outcomes were changes in self-reported patient communication skills, attitudes, and behaviors related to discussing disease progression, prognostic uncertainty, dialysis therapy withdrawal, treatments not indicated, and end of life; responding to emotion; eliciting patient goals and values; and incorporating patient goals into recommendations. MEASUREMENTS Surveys measured prior training, pre- and postcourse perceived changes in skills and values, and reported longer term (3-month) changes in communication behaviors, using both closed- and open-ended items. RESULTS Response rates were 100% (pre- and postsurveys) and 68% (follow-up). Participants reported improvement in all domains, with an overall mean increase of 1.1 (summed average scores: precourse, 2.8; postcourse, 3.9 [1-5 scale; 5 = "extremely well prepared"]; P<0.001), with improvement sustained at 3 months. Participants reported meaningful changes integrating into practice specific skills taught, such as "Ask-Tell-Ask" and using open-ended questions. LIMITATIONS Self-reported data may overestimate actual changes; small sample size and the programs' affiliation with a single medical school may limit generalizability. CONCLUSIONS A day-long course addressing nephrology fellows' communication competencies across the full course of patients' illness experience can enhance fellows' self-reported skills and practices.
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Affiliation(s)
- Robert A Cohen
- Nephrology Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
| | - Vicki A Jackson
- Palliative Care Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Diana Norwich
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Jane O Schell
- Section of Palliative Care and Medical Ethics and Renal Division-Electrolyte Division, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Kristen Schaefer
- Division of Psychosocial Medicine and Palliative Care, Dana Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Amy N Ship
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Amy M Sullivan
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
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Hing Wong A, Chin LE, Ping TL, Peng NK, Kun LS. Clinical Impact of Education Provision on Determining Advance Care Planning Decisions among End Stage Renal Disease Patients Receiving Regular Hemodialysis in University Malaya Medical Centre. Indian J Palliat Care 2016; 22:437-445. [PMID: 27803566 PMCID: PMC5072236 DOI: 10.4103/0973-1075.191788] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Advance care planning (ACP) is a process of shared decision-making about future health-care plans between patients, health care providers, and family members, should patients becomes incapable of participating in medical treatment decisions. ACP discussions enhance patient's autonomy, focus on patient's values and treatment preferences, and promote patient-centered care. ACP is integrated as part of clinical practice in Singapore and the United States. AIM To assess the clinical impact of education provision on determining ACP decisions among end-stage renal disease patients on regular hemodialysis at University Malaya Medical Centre (UMMC). To study the knowledge and attitude of patients toward ACP and end-of-life issues. MATERIALS AND METHODS Fifty-six patients were recruited from UMMC. About 43 questions pretest survey adapted from Lyon's ACP survey and Moss's cardiopulmonary resuscitation (CPR) attitude survey was given to patients to answer. An educational brochure is then introduced to these patients, and a posttest survey carried out after that. The results were analyzed using SPSS version 22.0. RESULTS Opinion on ACP, including CPR decisions, showed an upward trend on the importance percentage after the educational brochure exposure, but this was statistically not significant. Seventy-five percent of participants had never heard of ACP before, and only 3.6% had actually prepared a written advanced directive. CONCLUSION The ACP educational brochure clinically impacts patients' preferences and decisions toward end-of-life care; however, this is statistically not significant. Majority of patients have poor knowledge on ACP. This study lays the foundation for execution of future larger scale clinical trials, and ultimately, the incorporation of ACP into clinical practice in Malaysia.
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Affiliation(s)
| | - Loh Ee Chin
- University Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Tan Li Ping
- University Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Ng Kok Peng
- Department of Internal Medicine, University Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Lim Soo Kun
- University Malaya Medical Centre, Kuala Lumpur, Malaysia
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Carrero Planes V, Navarro Sanz R, Serrano Font M. Planificación adelantada de los cuidados en pacientes con enfermedades crónicasy necesidad de atención paliativa. ACTA ACUST UNITED AC 2016. [DOI: 10.1016/j.medipa.2013.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Watanabe Y, Hirakata H, Okada K, Yamamoto H, Tsuruya K, Sakai K, Mori N, Itami N, Inaguma D, Iseki K, Uchida A, Kawaguchi Y, Ohira S, Tomo M, Masakane I, Akizawa T, Minakuchi J. Proposal for the shared decision-making process regarding initiation and continuation of maintenance hemodialysis. Ther Apher Dial 2015; 19 Suppl 1:108-17. [PMID: 25817935 DOI: 10.1111/1744-9987.12295] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Executive summary of the KDIGO Controversies Conference on Supportive Care in Chronic Kidney Disease: developing a roadmap to improving quality care. Kidney Int 2015; 88:447-59. [PMID: 25923985 DOI: 10.1038/ki.2015.110] [Citation(s) in RCA: 327] [Impact Index Per Article: 36.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Revised: 02/17/2015] [Accepted: 03/04/2015] [Indexed: 12/30/2022]
Abstract
Patients with advanced chronic kidney disease (CKD) have a high burden of physical and psychosocial symptoms, poor outcomes, and high costs of care. Current paradigms of care for this highly vulnerable population are variable, prognostic and assessment tools are limited, and quality of care, particularly regarding conservative and palliative care, is suboptimal. The KDIGO Controversies Conference on Supportive Care in CKD reviewed the current state of knowledge in order to define a roadmap to guide clinical and research activities focused on improving the outcomes of people living with advanced CKD, including those on dialysis. An international group of multidisciplinary experts in CKD, palliative care, methodology, economics, and education identified the key issues related to palliative care in this population. The conference led to a working plan to address outstanding issues in this arena, and this executive summary serves as an output to guide future work, including the development of globally applicable guidelines.
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Roderick P, Rayner H, Tonkin-Crine S, Okamoto I, Eyles C, Leydon G, Santer M, Klein J, Yao GL, Murtagh F, Farrington K, Caskey F, Tomson C, Loud F, Murphy E, Elias R, Greenwood R, O’Donoghue D. A national study of practice patterns in UK renal units in the use of dialysis and conservative kidney management to treat people aged 75 years and over with chronic kidney failure. HEALTH SERVICES AND DELIVERY RESEARCH 2015. [DOI: 10.3310/hsdr03120] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundConservative kidney management (CKM) is recognised as an alternative to dialysis for a significant number of older adults with multimorbid stage 5 chronic kidney disease (CKD5). However, little is known about the way CKM is delivered or how it is perceived.AimTo determine the practice patterns for the CKM of older patients with CKD5, to inform service development and future research.Objectives(1) To describe the differences between renal units in the extent and nature of CKM, (2) to explore how decisions are made about treatment options for older patients with CKD5, (3) to explore clinicians’ willingness to randomise patients with CKD5 to CKM versus dialysis, (4) to describe the interface between renal units and primary care in managing CKD5 and (5) to identify the resources involved and potential costs of CKM.MethodsMixed-methods study. Interviews with 42 patients aged > 75 years with CKD5 and 60 renal unit staff in a purposive sample of nine UK renal units. Interviews informed the design of a survey to assess CKM practice, sent to all 71 UK units. Nineteen general practitioners (GPs) were interviewed concerning the referral of CKD patients to secondary care. We sought laboratory data on new CKD5 patients aged > 75 years to link with the nine renal units’ records to assess referral patterns.ResultsSixty-seven of 71 renal units completed the survey. Although terminology varied, there was general acceptance of the role of CKM. Only 52% of units were able to quantify the number of CKM patients. A wide range reflected varied interpretation of the designation ‘CKM’ by both staff and patients. It is used to characterise a future treatment option as well as non-dialysis care for end-stage kidney failure (i.e. a disease state equivalent to being on dialysis). The number of patients in the latter group on CKM was relatively small (median 8, interquartile range 4.5–22). Patients’ expectations of CKM and dialysis were strongly influenced by renal staff. In a minority of units, CKM was not discussed. When discussed, often only limited information about illness progression was provided. Staff wanted more research into the relative benefits of CKM versus dialysis. There was almost universal support for an observational methodology and a quarter would definitely be willing to participate in a randomised clinical trial, indicating that clinicians placed value on high-quality evidence to inform decision-making. Linked data indicated that most CKD5 patients were known to renal units. GPs expressed a need for guidance on when to refer older multimorbid patients with CKD5 to nephrology care. There was large variation in the scale and model of CKM delivery. In most, the CKM service was integrated within the service for all non-renal replacement therapy CKD5 patients. A few units provided dedicated CKM clinics and some had dedicated, modest funding for CKM.ConclusionsConservative kidney management is accepted across UK renal units but there is much variation in the way it is described and delivered. For best practice, and for CKM to be developed and systematised across all renal units in the UK, we recommend (1) a standard definition and terminology for CKM, (2) research to measure the relative benefits of CKM and dialysis and (3) development of evidence-based staff training and patient education interventions.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Paul Roderick
- Primary Care and Population Sciences, University of Southampton, UK
| | - Hugh Rayner
- Department of Renal Medicine, Heart of England NHS Foundation Trust, Birmingham, UK
| | | | - Ikumi Okamoto
- Primary Care and Population Sciences, University of Southampton, UK
| | - Caroline Eyles
- Primary Care and Population Sciences, University of Southampton, UK
| | - Geraldine Leydon
- Primary Care and Population Sciences, University of Southampton, UK
| | - Miriam Santer
- Primary Care and Population Sciences, University of Southampton, UK
| | - Jonathan Klein
- Southampton Management School, University of Southampton, UK
| | - Guiqing Lily Yao
- Primary Care and Population Sciences, University of Southampton, UK
| | - Fliss Murtagh
- Cicely Saunders Institute, King’s College London, UK
| | | | | | | | | | - Emma Murphy
- Cicely Saunders Institute, King’s College London, UK
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Goff SL, Eneanya ND, Feinberg R, Germain MJ, Marr L, Berzoff J, Cohen LM, Unruh M. Advance care planning: a qualitative study of dialysis patients and families. Clin J Am Soc Nephrol 2015; 10:390-400. [PMID: 25680737 DOI: 10.2215/cjn.07490714] [Citation(s) in RCA: 77] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES More than 90,000 patients with ESRD die annually in the United States, yet advance care planning (ACP) is underutilized. Understanding patients' and families' diverse needs can strengthen systematic efforts to improve ACP. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS In-depth interviews were conducted with a purposive sample of patients and family/friends from dialysis units at two study sites. Applying grounded theory, interviews were audiotaped, professionally transcribed, and analyzed in an iterative process. Emergent themes were identified, discussed, and organized into major themes and subthemes. RESULTS Thirteen patients and nine family/friends participated in interviews. The mean patient age was 63 years (SD 14) and five patients were women. Participants identified as black (n=1), Hispanic (n=4), Native American (n=4), Pacific Islander (n=1), white (n=11), and mixed (n=1). Three major themes with associated subthemes were identified. The first theme, "Prior experiences with ACP," revealed that these discussions rarely occur, yet most patients desire them. A potential role for the primary care physician was broached. The second theme, "Factors that may affect perspectives on ACP," included a desire for more of a connection with the nephrologist, positive and negative experiences with the dialysis team, disenfranchisement, life experiences, personality traits, patient-family/friend relationships, and power differentials. The third theme, "Recommendations for discussing ACP," included thoughts on who should lead discussions, where and when discussions should take place, what should be discussed and how. CONCLUSIONS Many participants desired better communication with their nephrologist and/or their dialysis team. A number expressed feelings of disenfranchisement that could negatively impact ACP discussions through diminished trust. Life experiences, personality traits, and relationships with family and friends may affect patient perspectives regarding ACP. This study's findings may inform clinical practice and will be useful in designing prospective intervention studies to improve patient and family experiences at the end of life.
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Affiliation(s)
- Sarah L Goff
- Divisions of General Medicine and Center for Quality of Care Research, and
| | - Nwamaka D Eneanya
- Division of Nephrology, Department of Internal Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Rebecca Feinberg
- Department of Psychiatry, Baystate Medical Center, Springfield, Massachusetts
| | | | - Lisa Marr
- Divisions of Geriatrics and Palliative Medicine and
| | - Joan Berzoff
- Smith College School for Social Work, Smith College, Northampton, Massachusetts
| | - Lewis M Cohen
- Department of Psychiatry, Baystate Medical Center, Springfield, Massachusetts
| | - Mark Unruh
- Nephrology, Department of Internal Medicine, University of New Mexico, Albuquerque, New Mexico; and
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38
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Tonkin-Crine S, Okamoto I, Leydon GM, Murtagh FEM, Farrington K, Caskey F, Rayner H, Roderick P. Understanding by older patients of dialysis and conservative management for chronic kidney failure. Am J Kidney Dis 2014; 65:443-50. [PMID: 25304984 PMCID: PMC4339698 DOI: 10.1053/j.ajkd.2014.08.011] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Accepted: 08/01/2014] [Indexed: 11/11/2022]
Abstract
Background Older adults with chronic kidney disease stage 5 may be offered a choice between dialysis and conservative management. Few studies have explored patients’ reasons for choosing conservative management and none have compared the views of those who have chosen different treatments across renal units. Study Design Qualitative study with semistructured interviews. Settings & Participants Patients 75 years or older recruited from 9 renal units. Units were chosen to reflect variation in the scale of delivery of conservative management. Methodology Semistructured interviews audiorecorded and transcribed verbatim. Analytical Approach Data were analyzed using thematic analysis. Results 42 interviews were completed, 4 to 6 per renal unit. Patients were sampled from those receiving dialysis, those preparing for dialysis, and those choosing conservative management. 14 patients in each group were interviewed. Patients who had chosen different treatments held varying beliefs about what dialysis could offer. The information that patients reported receiving from clinical staff differed between units. Patients from units with a more established conservative management pathway were more aware of conservative management, less often believed that dialysis would guarantee longevity, and more often had discussed the future with staff. Some patients receiving conservative management reported that they would have dialysis if they became unwell in the future, indicating the conditional nature of their decision. Limitations Recruitment of older adults with frailty and comorbid conditions was difficult and therefore transferability of findings to this population is limited. Conclusions Older adults with chronic kidney disease stage 5 who have chosen different treatment options have contrasting beliefs about the likely outcomes of dialysis for those who are influenced by information provided by renal units. Supporting renal staff in discussing conservative management as a valid alternative to dialysis for a subset of patients will aid informed decision making. There is a need for better evidence about conservative management to support shared decision making for older people with chronic kidney failure.
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Affiliation(s)
- Sarah Tonkin-Crine
- Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, United Kingdom.
| | - Ikumi Okamoto
- Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Geraldine M Leydon
- Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Fliss E M Murtagh
- Department of Palliative Care, Policy and Rehabilitation, King's College London, London, United Kingdom
| | | | - Fergus Caskey
- Renal Unit, Southmead Hospital, Bristol, United Kingdom
| | - Hugh Rayner
- Department of Renal Medicine, Heart of England NHS Foundation Trust, Birmingham, United Kingdom
| | - Paul Roderick
- Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
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39
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Affiliation(s)
- David N Churchill
- Division of Nephrology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada, and
| | - Sarbjit Vanita Jassal
- Division of Nephrology, University Health Network, University of Toronto, Toronto, Ontario, Canada
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40
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Luckett T, Sellars M, Tieman J, Pollock CA, Silvester W, Butow PN, Detering KM, Brennan F, Clayton JM. Advance Care Planning for Adults With CKD: A Systematic Integrative Review. Am J Kidney Dis 2014; 63:761-70. [DOI: 10.1053/j.ajkd.2013.12.007] [Citation(s) in RCA: 75] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2013] [Accepted: 12/17/2013] [Indexed: 01/24/2023]
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41
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Abstract
Acceleration of comorbid illness in patients undergoing long-term maintenance hemodialysis may be manifested by clinical deterioration that is subtle and not immediately life-threatening. Nonetheless, it is emotionally debilitating for patients and families in addition to being medically and ethically challenging for treating nephrologists. A marked decline in clinical status warrants review of the balance of benefits to burdens dialysis is providing to a given patient and should trigger conversation about the option of withdrawal using an individualized patient-centered, rather than disease-oriented, approach. This paper presents a rationale for and an objective approach to initiating and managing dialysis withdrawal for patients who wish to withdraw because of unsatisfactory quality of life and those (many with significant cognitive impairment) for whom withdrawal is deemed appropriate because the burdens of continuing treatment substantially outweigh the benefits.
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Affiliation(s)
| | - Alvin H. Moss
- Sections of Nephrology and
- Supportive Care, Department of Medicine, West Virginia University School of Medicine, Morgantown, West Virginia
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42
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43
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Wong SPY, Kreuter W, O'Hare AM. Healthcare intensity at initiation of chronic dialysis among older adults. J Am Soc Nephrol 2013; 25:143-9. [PMID: 24262795 DOI: 10.1681/asn.2013050491] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Little is known about the circumstances under which older adults initiate chronic dialysis and subsequent outcomes. Using national registry data, we conducted a retrospective analysis of 416,657 Medicare beneficiaries aged ≥67 years who initiated chronic dialysis between January 1995 and December 2008. Our goal was to define the relationship between health care intensity around the time of dialysis initiation and subsequent survival and patterns of hospitalization, use of intensive procedures (mechanical ventilation, feeding tube placement, and cardiopulmonary resuscitation), and discontinuation of dialysis before death. We found that most patients (64.5%) initiated dialysis in the hospital, including 36.6% who were hospitalized for ≥2 weeks and 7.4% who underwent one or more intensive procedures. Compared with patients who initiated dialysis in the outpatient setting, those who received the highest intensity of care at dialysis initiation (those hospitalized ≥2 weeks and receiving at least one intensive procedure) had a shorter median survival (0.7 versus 2.1 years; P<0.001), spent a greater percentage of remaining follow-up time in the hospital (median, 22.9% versus 3.1%; P<0.001), were more likely to undergo subsequent intensive procedures (44.9% versus 26.0%; adjusted hazard ratio, 2.33; 95% confidence interval [CI], 2.27 to 2.39), and were less likely to have discontinued dialysis before death (19.1% versus 26.2%; adjusted odds ratio, 0.68; 95% CI, 0.65 to 0.72). In conclusion, most older adults initiate chronic dialysis in the hospital. Those who have a prolonged hospital stay and receive other forms of life support around the time of dialysis initiation have limited survival and more intensive patterns of subsequent healthcare utilization.
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44
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Kane PM, Vinen K, Murtagh FEM. Palliative care for advanced renal disease: a summary of the evidence and future direction. Palliat Med 2013; 27:817-21. [PMID: 23765187 DOI: 10.1177/0269216313491796] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Patients with end-stage kidney disease can have a significant symptom burden with complex co-morbidities. Compounding this is the choice between dialysis and conservative management. NEED FOR SUPPORTIVE AND PALLIATIVE CARE: For individuals with end-stage kidney disease, palliative care can provide support with symptom management, advance care planning and psychological support and education for both patients and their families. Optimum management may be achieved through collaboration between renal and palliative care professionals, combining their different skills in addressing symptom and medication management. Palliative and supportive care must be patient-centred to be effective. Multidisciplinary cross-organisational input is central to address the complex care needs of these patients, particularly for those in the community. WHAT IS KNOWN/WHAT IS NOT KNOWN: There is growing awareness of the need for research into the palliative care needs of those with end-stage kidney disease. Research has shown that patients receiving dialysis may prioritise quality of life over survival time, partly due to the constraints that they feel dialysis imposes on them. Systematic study of those opting for a conservative management pathway rather than dialysis is beginning to happen. RESEARCH IMPLICATIONS Research is required into what underpins the preferences and priorities of patients with end-stage kidney disease to provide them with the best palliative and supportive care. POLICY AND PRACTICE: As more patients opt to follow the conservative pathway for their advanced renal disease, a change in service provision is required, with greater regular inclusion of palliative and supportive needs to address the gap in the care provision for this growing group.
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Affiliation(s)
- Pauline M Kane
- King's College London, Department of Palliative Care, Policy and Rehabilitation, Cicely Saunders Institute, London, UK
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45
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Abstract
BACKGROUND The role played by emergency contacts can be extensive particularly for chronically seriously ill patients. If the patient's condition suddenly deteriorates, the emergency contact may be asked to make decisions that should instead fall to a designated surrogate decision-maker. AIMS To describe a process used to help chronically seriously ill patients identify a surrogate during study enrollment and to describe whether these surrogates were the same as the documented emergency contacts. DESIGN A descriptive cross-sectional study using eligibility assessment and baseline data from an efficacy trial. The parent trial tests the effects of an end-of-life communication intervention on patient and surrogate decision-maker outcomes, and thus, it was important to identify the surrogate. The study recruiter used a short battery of investigator-developed questions to help patients identify a surrogate. SETTING/PARTICIPANTS Patients were 94 self-identified African Americans or Caucasians recruited from 18 outpatient dialysis centers, receiving dialysis for ≥6 months, with Charlson Comorbidity Index of ≥6 or 5 and hospitalized in the last 6 months. RESULTS When first approached, only three patients had a designated and documented surrogate. The remaining 91 selected a surrogate during the surrogate identification process. Of the 94 surrogates who were named, only 60 (63.8%) were also listed in the medical record as the emergency contact. CONCLUSIONS In roughly one-third of instances, the selected surrogate was not the same person listed in official medical records as the emergency contact, which may pose potential problems in medical decision-making in the absence of advance directives.
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Affiliation(s)
- Mi-Kyung Song
- School of Nursing, University of North Carolina, Chapel Hill, NC, USA.
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46
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Brown MA, Crail SM, Masterson R, Foote C, Robins J, Katz I, Josland E, Brennan F, Stallworthy EJ, Siva B, Miller C, Urban AK, Sajiv C, Glavish RN, May S, Langham R, Walker R, Fassett RG, Morton RL, Stewart C, Phipps L, Healy H, Berquier I. ANZSN Renal Supportive Care Guidelines 2013. Nephrology (Carlton) 2013; 18:401-454. [DOI: 10.1111/nep.12065] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/02/2013] [Indexed: 12/16/2022]
Affiliation(s)
- Mark A Brown
- Departments of Renal Medicine and Medicine; St George Hospital and University of NSW; Sydney New South Wales Australia
| | - Susan M Crail
- Central and North Adelaide Renal and Transplantation Service; Adelaide South Australia Australia
- Central and North Adelaide Renal and Transplant Services; Adelaide South Australia Australia
| | - Rosemary Masterson
- Department of Nephrology; Royal Melbourne Hospital; Melbourne Victoria Australia
| | - Celine Foote
- The George Institute for Global Health; Sydney New South Wales Australia
| | - Jennifer Robins
- Departments of Renal Medicine and Medicine; St George Hospital and University of NSW; Sydney New South Wales Australia
| | - Ivor Katz
- Departments of Renal Medicine and Medicine; St George Hospital and University of NSW; Sydney New South Wales Australia
| | | | - Frank Brennan
- Departments of Renal Medicine and Palliative Medicine; St George Hospital; Kogarah New South Wales Australia
- Deparments of Renal Medicine and Palliative Medicine; St George Hospital; Kogarah New South Wales Australia
| | | | - Brian Siva
- Fremantle Hospital; Fremantle Western Australia Australia
| | - Cathy Miller
- Palliative Care Service; Department of General Medicine; North Shore and Waitakere Hospitals; Waitemata District Health Board; Auckland New Zealand
| | - A Katalin Urban
- Concord Repatriation Hospital; Concord; New South Wales Australia
| | - Cherian Sajiv
- Alice Springs Hospital; Central Australian Renal Services; Alice Springs Northern Territory Australia
| | - R Naida Glavish
- He Kamaka Oranga - Department of Maori Health; Auckland District Health Board; Auckland New Zealand
| | - Steven May
- Tamworth Base Hospital; Tamworth New South Wales Australia
| | | | - Robert Walker
- Department of Medicine; Dunedin School of Medicine; University of Otago; Dunedin New Zealand
| | - Robert G Fassett
- Royal Brisbane and Women's Hospital; Herston Queensland Australia
| | - Rachael L Morton
- School of Public Health; University of Sydney; Sydney New South Wales Australia
| | - Cameron Stewart
- Centre for Health Governance, Law & Ethics; Sydney Law School; University of Sydney; Sydney
| | - Lisa Phipps
- Orange Base Hospital; Orange New South Wales Australia
| | - Helen Healy
- Deparment of Renal Medicine; Royal Brisbane and Women's Hospital; Brisbane Queensland Australia
| | - Ilse Berquier
- Central and North Adelaide Renal and Transplant Services; Adelaide South Australia Australia
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Janssen DJA, Spruit MA, Schols JMGA, van der Sande FM, Frenken LA, Wouters EFM. Insight into advance care planning for patients on dialysis. J Pain Symptom Manage 2013; 45:104-13. [PMID: 22841410 DOI: 10.1016/j.jpainsymman.2012.01.010] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2011] [Revised: 01/15/2012] [Accepted: 01/19/2012] [Indexed: 11/23/2022]
Abstract
CONTEXT Advance care planning is not included in regular clinical care for patients on dialysis. Insight into life-sustaining treatment preferences and communication about end-of-life care is necessary to develop interventions to improve advance care planning for patients on dialysis. OBJECTIVES This cross-sectional observational study aimed to understand the preferences for life-sustaining treatments of outpatients on dialysis and to study the quality of patient-physician communication about end-of-life care and barriers and facilitators to this communication. METHODS The following outcomes were assessed in 80 clinically stable dialysis patients: demographics, clinical characteristics, life-sustaining treatment preferences (cardiopulmonary resuscitation and mechanical ventilation, and Willingness to Accept Life-Sustaining Treatment instrument), preference for site of death, quality of communication (Quality of Communication Questionnaire), and barriers and facilitators to communication about end-of-life care (Barriers and Facilitators Questionnaire). RESULTS Patients were able to indicate their preferences for life-sustaining treatments and site of death. Preferences for life-sustaining treatments depend on the specific treatment, the expected outcome of treatment, and likelihood of an adverse outcome. Life-sustaining preferences were discussed with the nephrologist by 30.3% of the patients. Quality of the patient-physician communication about end-of-life care was rated poor. This study identified several barriers and facilitators to end-of-life care communication. CONCLUSION Patients should receive information about treatment burden, expected outcome, and the likelihood of an adverse outcome when discussing life-sustaining treatments. Quality of patient-physician communication about end-of-life care needs to improve. Barriers and facilitators to communication about end-of-life care provide direction for future interventions to facilitate advance care planning for patients on dialysis.
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Affiliation(s)
- Daisy J A Janssen
- Program Development Centre, Centre of Expertise for Chronic Organ Failure, Horn, The Netherlands.
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48
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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. Can J Aging 2012; 31:435-44. [DOI: 10.1017/s0714980812000335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
ABSTRACTThe 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.
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49
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50
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Abstract
Patients with ESRD have extensive and unique palliative care needs, often for years before death. The vast majority of patients, however, dies in acute care facilities without accessing palliative care services. High mortality rates along with a substantial burden of physical, psychosocial, and spiritual symptoms and an increasing prevalence of decisions to withhold and stop dialysis all highlight the importance of integrating palliative care into the comprehensive management of ESRD patients. The focus of renal care would then extend to controlling symptoms, communicating prognosis, establishing goals of care, and determining end-of-life care preferences. Regretfully, training in palliative care for nephrology trainees is inadequate. This article will provide a conceptual framework for renal palliative care and describe opportunities for enhancing palliative care for ESRD patients, including improved chronic pain management and advance care planning and a new model for delivering high-quality palliative care that includes appropriate consultation with specialist palliative care.
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Affiliation(s)
- Sara N Davison
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.
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