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Moranne O, Hamroun A, Couchoud C. What does the French REIN registry tell us about Stage 4-5 CKD care in older adults? FRONTIERS IN NEPHROLOGY 2023; 2:1026874. [PMID: 37675001 PMCID: PMC10479600 DOI: 10.3389/fneph.2022.1026874] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 12/02/2022] [Indexed: 09/08/2023]
Abstract
The aim of this paper is to illustrate all the clinical epidemiology searches made within the French network REIN to improve CKD stage 4-5 care in older adults. We summarize various studies describing clinical practice, care organization, prognosis and health economics evaluation in order to develop personalized care plans and decision-making tools. In France, for 20 years now, various databases have been mobilized including the national REIN registry which includes all patients receiving dialysis or transplantation. REIN data are indirectly linked to the French administrative healthcare database. They are also pooled with data from the PSPA cohort, a multicenter prospective cohort study of patients aged 75 or over with advanced CKD, monitored for 5 years, and the CKD-REIN clinical-based prospective cohort which included 3033 patients with CKD stage 3-4 from 2013 to 2016. During our various research work, we identified heterogeneous trajectories specific to this growing older population, raising ethical, organizational and economic issues. Renal registries will help clinicians, health providers and policy-makers if suitable decision- making tools are developed and validated.
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Affiliation(s)
- Olivier Moranne
- Service Néphrologie-Dialyse-Aphérèse, Hôpital Universitaire de Nîmes, Hôpital Carémeau, Nîmes, France
- UMR Inserm-UM, Institut Desbrest d'Epidemiologie et Santé publique (IDESP), Montpellier, France
| | - Aghilès Hamroun
- Service de Santé Publique, Service de Néphrologie-Dialyse-Transplantation rénale-Aphérèse, Hôpital Universitaire de Lille, Hôpital Huriez, Lille, France
| | - Cécile Couchoud
- French REIN registry, Agence de la biomédecine, La Plaine Saint-Denis, France
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Haug K, Buffington A, Zelenski A, Hanlon BM, Stalter L, Kwekkeboom KL, Rathouz P, Bansal AD, Cheung K, Crews D, Frazier R, Koncicki H, Lam D, Moss A, Rao M, Wolfgram DF, Yi J, Brill C, Kendrick R, Campbell TC, Jhagroo R, Schwarze M. Best Case/Worst Case: protocol for a multisite randomised clinical trial of a scenario planning intervention for patients with kidney failure. BMJ Open 2022; 12:e067258. [PMID: 36328383 PMCID: PMC9639110 DOI: 10.1136/bmjopen-2022-067258] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
INTRODUCTION Given the burdens of treatment and poor prognosis, older adults with kidney failure would benefit from improved decision making and palliative care to clarify goals, address symptoms, and reduce unwanted procedures. Best Case/Worst Case (BC/WC) is a communication tool that uses scenario planning to support patients' decision making. This article describes the protocol for a multisite, cluster randomised trial to test the effect of training nephrologists to use the BC/WC communication tool on patient receipt of palliative care, and quality of life and communication. METHODS AND ANALYSIS We are enrolling attending nephrologists, at 10 study sites in the USA, who see outpatients with advanced chronic kidney disease considering dialysis. We aim to enrol 320 patients with an estimated glomerular filtration rate of ≤24 mL/min/1.73 m2 who are age 60 and older and have a predicted survival of 18 months or less. Nephrologists will be randomised in a 1:1 ratio to receive training to use the communication tool (intervention) at study initiation or after study completion (wait-list control). Patients in the intervention group will receive care from a nephrologist trained to use the BC/WC communication tool. Patients in the control group will receive usual care. Using chart review and surveys of patients and caregivers, we will test the efficacy of the BC/WC intervention with receipt of palliative care as the primary outcome. Secondary outcomes include intensity of treatment at the end of life, the effect of the intervention on quality of communication (QOC) between nephrologists and patients (using the QOC scale), the change in quality of life (using the Functional Assessment of Chronic Illness Therapy-Palliative Care scale) and receipt of dialysis. ETHICS AND DISSEMINATION Approvals have been granted by the Institutional Review Board at the University of Wisconsin (ID: 2022-0193), with each study site ceding review to the primary IRB. All nephrologists will be consented and given a copy of the consent form. No patients or caregivers will be recruited or consented until their nephrology provider has chosen to participate in the study. Results will be disseminated via submission for publication in a peer-reviewed journal and at national meetings. TRIAL REGISTRATION NUMBER NCT04466865.
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Affiliation(s)
- Karlie Haug
- Department of Surgery, University of Wisconsin, Madison, Wisconsin, USA
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Anne Buffington
- Department of Surgery, University of Wisconsin, Madison, Wisconsin, USA
| | - Amy Zelenski
- Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Bret M Hanlon
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
- Department of Biostatistics & Medical Informatics, University of Wisconsin, Madison, WI, USA
| | - Lily Stalter
- Department of Surgery, University of Wisconsin, Madison, Wisconsin, USA
| | - Kristine L Kwekkeboom
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
- School of Nursing, University of Wisconsin, Madison, WI, USA
| | - Paul Rathouz
- Department of Biostatistics & Medical Informatics, University of Wisconsin, Madison, WI, USA
| | - Amar D Bansal
- Division of Nephrology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Katharine Cheung
- Division of Nephrology, University of Vermont, Burlington, Vermont, USA
| | - Deidra Crews
- Division of Nephrology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Rebecca Frazier
- Division of Nephrology, Northwestern Memorial HealthCare Corp, Chicago, Illinois, USA
| | - Holly Koncicki
- Division of Nephrology, Mount Sinai Health System, New York, New York, USA
| | - Daniel Lam
- Division of Nephrology, University of Washington, Seattle, Washington, USA
| | - Alvin Moss
- Section of Nephrology, West Virginia University, Morgantown, West Virginia, USA
| | - Maya Rao
- Division of Nephrology, Columbia University, New York, New York, USA
| | - Dawn F Wolfgram
- Division of Nephrology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Jeniann Yi
- Department of Surgery, University of Colorado Health, Aurora, Colorado, USA
| | | | | | - Toby C Campbell
- Department of Medicine, University of Wisconsin, Madison, Wisconsin, USA
| | - Roy Jhagroo
- Department of Medicine, University of Wisconsin, Madison, Wisconsin, USA
| | - Margaret Schwarze
- Department of Surgery, University of Wisconsin, Madison, Wisconsin, USA
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
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Hemmat V, Corbett C. Palliative Care for Nephrology Patients in the Intensive Care Unit. Crit Care Nurs Clin North Am 2022; 34:467-479. [DOI: 10.1016/j.cnc.2022.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Ethical Challenges When Caring for African American Older Adults Requesting to Withdraw From Dialysis. J Hosp Palliat Nurs 2022; 24:209-217. [PMID: 35488364 DOI: 10.1097/njh.0000000000000862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The number of African American adults 65 years and older with end-stage kidney disease receiving maintenance hemodialysis is increasing. The high symptom burden (ie, pain, fatigue, depression) can make it challenging for many to continue dialysis, which can lead to request to withdraw from dialysis. This can present ethical challenges when someone has diminished decision-making capacity and no advance directives or family to assist with this complex decision. This article will provide a brief overview of ethical issues to consider when responding to an older adult's request to withdraw from a life-sustaining treatment such as dialysis. Suggestions for research to address the gaps in knowledge will be presented.
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Ernecoff NC, Bell LF, Arnold RM, Shea CM, Switzer GE, Jhamb M, Schell JO, Kavalieratos D. Clinicians' Perceptions of Collaborative Palliative Care Delivery in Chronic Kidney Disease. J Pain Symptom Manage 2022; 64:168-177. [PMID: 35417752 PMCID: PMC9276626 DOI: 10.1016/j.jpainsymman.2022.04.167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 03/29/2022] [Accepted: 04/05/2022] [Indexed: 11/20/2022]
Abstract
CONTEXT Guidelines recommend palliative care for patients with chronic kidney disease (CKD), who experience a high pain and symptom burden, and receive intensive treatments that often do not align with their values. A lack of scalable specialty palliative care services has prompted calls for attention to primary palliative care, delivered in primary care and nephrology settings. OBJECTIVES The objectives of this study were to 1) describe expectations for care to meet the palliative care needs of people living with CKD, and limitations to meeting those expectations in the current model, and 2) identify potential interventions to meet patients' palliative care needs. METHODS We conducted semi-structured interviews with clinicians from primary care, nephrology, and palliative care to assess 1) reasonable expectations for meeting palliative needs, 2) barriers to integrating primary palliative care, and 3) potential intervention points. RESULTS Clinicians discussed their expectations for high-quality communication (e.g., discussing disease understanding, assessing goals of care) and better integration of palliative care services. Clinicians expressed barriers to delivering that care, including poor inter-clinician communication. To address barriers, clinicians outlined potential intervention points, such as building collaborative models of care, and structural triggers to identify patients who may be appropriate for palliative care. CONCLUSION Interventions to address gaps in palliative care delivery for people living with CKD should incorporate systematic identification of patients with palliative care needs and structural mechanisms to meeting those needs via specialty and primary palliative care.
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Affiliation(s)
- Natalie C Ernecoff
- RAND Corporation (N.C.E.), Pittsburgh, Pennsylvania, USA; Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh (N.C.E., L.F.B., R.M.A., J.O.S.), Pittsburgh, Pennsylvania, USA.
| | - Lindsay F Bell
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh (N.C.E., L.F.B., R.M.A., J.O.S.), Pittsburgh, Pennsylvania, USA
| | - Robert M Arnold
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh (N.C.E., L.F.B., R.M.A., J.O.S.), Pittsburgh, Pennsylvania, USA
| | - Christopher M Shea
- Department of Health Policy and Management, University of North Carolina at Chapel Hill (C.M.S.), Chapel Hill, North Carolina, USA
| | - Galen E Switzer
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh (G.E.S.), Pittsburgh, Pennsylvania, USA; Department of Psychiatry, University of Pittsburgh (G.E.S.), Pittsburgh, Pennsylvania, USA; Department of Clinical and Translational Science, University of Pittsburgh (G.E.S.), Pittsburgh, Pennsylvania, USA; Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System (G.E.S.), Pittsburgh, Pennsylvania, USA
| | - Manisha Jhamb
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh (M.J.), Pittsburgh, Pennsylvania, USA
| | - Jane O Schell
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh (N.C.E., L.F.B., R.M.A., J.O.S.), Pittsburgh, Pennsylvania, USA
| | - Dio Kavalieratos
- Division of Palliative Medicine, Department of Family and Preventive Medicine, Emory University School of Medicine (D.K.), Atlanta, Georgia, USA
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Eneanya ND, Lakin JR, Paasche-Orlow MK, Lindvall C, Moseley ET, Henault L, Hanchate AD, Mandel EI, Wong SPY, Zupanc SN, Davis AD, El-Jawahri A, Quintiliani LM, Chang Y, Waikar SS, Bansal AD, Schell JO, Lundquist AL, Tamura MK, Yu MK, Unruh ML, Argyropoulos C, Germain MJ, Volandes A. Video Images about Decisions for Ethical Outcomes in Kidney Disease (VIDEO-KD): the study protocol for a multi-centre randomised controlled trial. BMJ Open 2022; 12:e059313. [PMID: 35396311 PMCID: PMC8996022 DOI: 10.1136/bmjopen-2021-059313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Older patients with advanced chronic kidney disease (CKD) often are inadequately prepared to make informed decisions about treatments including dialysis and cardiopulmonary resuscitation. Further, evidence shows that patients with advanced CKD do not commonly engage in advance care planning (ACP), may suffer from poor quality of life, and may be exposed to end-of-life care that is not concordant with their goals. We aim to study the effectiveness of a video intervention on ACP, treatment preferences and other patient-reported outcomes. METHODS AND ANALYSIS The Video Images about Decisions for Ethical Outcomes in Kidney Disease trial is a multi-centre randomised controlled trial that will test the effectiveness of an intervention that includes a CKD-related video decision aid followed by recording personal video declarations about goals of care and treatment preferences in older adults with advancing CKD. We aim to enrol 600 patients over 5 years at 10 sites. ETHICS AND DISSEMINATION Regulatory and ethical aspects of this trial include a single Institutional Review Board mechanism for approval, data use agreements among sites, and a Data Safety and Monitoring Board. We intend to disseminate findings at national meetings and publish our results. TRIAL REGISTRATION NUMBER NCT04347629.
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Affiliation(s)
- Nwamaka D Eneanya
- Renal-Electrolyte and Hypertension Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA, USA
| | - Joshua R Lakin
- Harvard Medical School, Boston, Massachusetts, USA
- Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Michael K Paasche-Orlow
- Boston University School of Medicine, Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Charlotta Lindvall
- Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Edward T Moseley
- Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Lori Henault
- Boston University School of Medicine, Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Amresh D Hanchate
- Department of Social Sciences and Health Policy, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Ernest I Mandel
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Renal (Kidney) Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Susan P Y Wong
- University of Washington, Seattle, Washington State, USA
| | - Sophia N Zupanc
- Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | | | - Areej El-Jawahri
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Lisa M Quintiliani
- Boston University School of Medicine, Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Yuchiao Chang
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sushrut S Waikar
- Section of Nephrology, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts, USA
| | - Amar D Bansal
- Section of Palliative Care and Medical Ethics, Department of General Medicine, Division of Renal-Electrolyte, University of Pittsburgh School of Medicine, UPMC Health System, Pittsburgh, Pennsylvania, USA
| | - Jane O Schell
- Section of Palliative Care and Medical Ethics, Department of General Medicine, Division of Renal-Electrolyte, University of Pittsburgh School of Medicine, UPMC Health System, Pittsburgh, Pennsylvania, USA
| | - Andrew L Lundquist
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Manjula Kurella Tamura
- Division of Nephrology, Stanford University School of Medicine; and Geriatric Research Education Clinical Center, VA Palo Alto Health Care System, Palo Alto, California, USA
| | - Margaret K Yu
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Mark L Unruh
- Department of Medicine, University of New Mexico, Albuquerque, New Mexico, USA
| | - Christos Argyropoulos
- Division of Nephrology, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
| | - Michael J Germain
- Baystate Medical Center-University of Massachusetts Springfield, Springfield, Massachusetts, USA
| | - Angelo Volandes
- Harvard Medical School, Boston, Massachusetts, USA
- ACP Decisions Non-profit Foundation, Newton, Massachusetts, USA
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
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Bernacki GM, McDermott CL, Matlock DD, O'Hare AM, Brumback L, Bansal N, Kirkpatrick JN, Engelberg RA, Curtis JR. Advance Care Planning Documentation and Intensity of Care at the End of Life for Adults With Congestive Heart Failure, Chronic Kidney Disease, and Both Illnesses. J Pain Symptom Manage 2022; 63:e168-e175. [PMID: 34363954 PMCID: PMC8814047 DOI: 10.1016/j.jpainsymman.2021.07.030] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Revised: 07/28/2021] [Accepted: 07/30/2021] [Indexed: 02/03/2023]
Abstract
CONTEXT Heart failure (HF) and chronic kidney disease (CKD) are associated with high morbidity and mortality, especially in combination, yet little is known about the impact of these conditions together on end-of-life care. OBJECTIVES Compare end-of-life care and advance care planning (ACP) documentation among patients with both HF and CKD to those with either condition. METHODS We conducted a retrospective analysis of deceased patients (2010-2017) with HF and CKD (n = 1673), HF without CKD (n = 2671), and CKD without HF (n = 1706), excluding patients with cancer or dementia. We compared hospitalizations and intensive care unit (ICU) admissions in the last 30 days of life, hospital deaths, and ACP documentation >30 days before death. RESULTS 39% of patients with HF and CKD were hospitalized and 33% were admitted to the ICU in the last 30 days vs. 30% and 28%, respectively, for HF, and 26% and 23% for CKD. Compared to patients with both conditions, those with only 1 were less likely to be admitted to the hospital [HF: adjusted odds ratio (aOR) 0.72, 95%CI 0.63-0.83; CKD: aOR 0.63, 95%CI 0.53-0.75] and ICU (HF: aOR 0.83, 95%CI 0.71-0.94; CKD: aOR 0.68, 95%CI 0.56-0.80) and less likely to have ACP documentation (aOR 0.53, 95%CI 0.47-0.61 and aOR 0.70, 95%CI 0.60-0.81). CONCLUSIONS Decedents with both HF and CKD had more ACP documentation and received more intensive end-of-life care than those with only 1 condition. These findings suggest that patients with co-existing HF and CKD may benefit from interventions to ensure care received aligns with their goals.
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Affiliation(s)
- Gwen M Bernacki
- Cambia Palliative Care Center of Excellence, University of Washington (G.M.B., C.L.M., J.R.C.), Seattle, WA; Division of Cardiology, Department of Medicine, University of Washington (G.M.B., J.N.K.), Seattle, WA; Hospital and Specialty Medicine Service, VA Puget Sound Health Care System (G.M.B., A.M.H. ), Seattle, WA.
| | - Cara L McDermott
- Cambia Palliative Care Center of Excellence, University of Washington (G.M.B., C.L.M., J.R.C.), Seattle, WA
| | - Daniel D Matlock
- Division of Geriatrics, Department of Medicine, University of Colorado School of Medicine (D.D.M.), Aurora, CO; VA Eastern Colorado Geriatric Research Education and Clinical Center (D.D.M.), Denver, CO
| | - Ann M O'Hare
- Hospital and Specialty Medicine Service, VA Puget Sound Health Care System (G.M.B., A.M.H. ), Seattle, WA; Division of Nephrology, Department of Medicine, University of Washington (A.M.O., N.B.), Seattle; Kidney Research Institute, University of Washington (A.M.O., N.B.)
| | - Lyndia Brumback
- Department of Biostatistics, University of Washington (L.B.), Seattle
| | - Nisha Bansal
- Division of Nephrology, Department of Medicine, University of Washington (A.M.O., N.B.), Seattle; Kidney Research Institute, University of Washington (A.M.O., N.B.)
| | - James N Kirkpatrick
- Division of Cardiology, Department of Medicine, University of Washington (G.M.B., J.N.K.), Seattle, WA; Department of Bioethics and Humanities, University of Washington (J.N.K., R.A.E.), Seattle, WA
| | - Ruth A Engelberg
- Cambia Palliative Care Center of Excellence, University of Washington (G.M.B., C.L.M., J.R.C.), Seattle, WA; Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington (R.A.E., J.R.C.), Seattle, WA; Department of Bioethics and Humanities, University of Washington (J.N.K., R.A.E.), Seattle, WA
| | - Jared Randall Curtis
- Cambia Palliative Care Center of Excellence, University of Washington (G.M.B., C.L.M., J.R.C.), Seattle, WA; Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington (R.A.E., J.R.C.), Seattle, WA
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Carswell C, Yaqoob M, Gilbert P, Kuan Y, Laurente G, McGuigan K, McKeaveney C, McVeigh C, Reid J, Rej S, Walsh I, Noble H. Exploration of Caregiver Experiences of Conservatively Managed End-Stage Kidney Disease to Inform Development of a Psychosocial Intervention: The ACORN Study Protocol. Healthcare (Basel) 2021; 9:healthcare9121731. [PMID: 34946457 PMCID: PMC8701309 DOI: 10.3390/healthcare9121731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 12/08/2021] [Accepted: 12/09/2021] [Indexed: 11/16/2022] Open
Abstract
Background: End-stage kidney disease (ESKD) is an overwhelming illness that impacts not just patients, but also their informal carers. Patients who opt for conservative management rather than dialysis experience difficult symptoms and the psychosocial consequences of their condition. Informal carers of patients who choose conservative management can also experience high levels of psychosocial burden, yet there is little guidance on how best to support informal carers, and no evidence on psychosocial interventions to address unmet needs. Aim: The aim of this study is to explore the experiences and unmet needs of informal carers of patients with ESKD receiving conservative management in order to inform the development of a psychosocial intervention. Methods: This qualitative study will consist of three stages: (I) semi-structured interviews with informal carers in England and Northern Ireland, (II) focus groups with healthcare professionals and informal carers, and (III) national workshops to refine the components of a psychosocial intervention. Discussion: Informal carers of patients with ESKD who are receiving conservative management experience a high psychosocial burden, but there is limited evidence on how best to provide support, particularly as the patient nears the end of life. To our knowledge this study will be the first to address this gap by exploring the experiences and unmet needs of informal carers, with the aim of informing the development of a psychosocial intervention to support the health and wellbeing of informal carers.
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Affiliation(s)
- Claire Carswell
- School of Nursing and Midwifery, Queen’s University Belfast, Belfast BT7 1NN, UK; (G.L.); (K.M.); (C.M.); (C.M.); (J.R.); (H.N.)
- Department of Health Sciences, University of York, York YO10 5DD, UK
- Correspondence:
| | | | - Patricia Gilbert
- Northern Ireland Kidney Patient Association, Belfast BT9 7AB, UK;
| | - Ying Kuan
- Western Health and Social Care Trust, Londonderry BT47 6SB, UK;
| | - Gladys Laurente
- School of Nursing and Midwifery, Queen’s University Belfast, Belfast BT7 1NN, UK; (G.L.); (K.M.); (C.M.); (C.M.); (J.R.); (H.N.)
- Barts Health NHS Trust, London E1 1BB, UK;
| | - Karen McGuigan
- School of Nursing and Midwifery, Queen’s University Belfast, Belfast BT7 1NN, UK; (G.L.); (K.M.); (C.M.); (C.M.); (J.R.); (H.N.)
| | - Clare McKeaveney
- School of Nursing and Midwifery, Queen’s University Belfast, Belfast BT7 1NN, UK; (G.L.); (K.M.); (C.M.); (C.M.); (J.R.); (H.N.)
| | - Clare McVeigh
- School of Nursing and Midwifery, Queen’s University Belfast, Belfast BT7 1NN, UK; (G.L.); (K.M.); (C.M.); (C.M.); (J.R.); (H.N.)
| | - Joanne Reid
- School of Nursing and Midwifery, Queen’s University Belfast, Belfast BT7 1NN, UK; (G.L.); (K.M.); (C.M.); (C.M.); (J.R.); (H.N.)
| | - Soham Rej
- Department of Psychiatry, Jewish General Hospital/Lady Davis Institute, McGill University, Montréal, QC H3A 0G4, Canada;
| | - Ian Walsh
- School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Belfast BT7 1NN, UK;
| | - Helen Noble
- School of Nursing and Midwifery, Queen’s University Belfast, Belfast BT7 1NN, UK; (G.L.); (K.M.); (C.M.); (C.M.); (J.R.); (H.N.)
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Ernecoff NC, Abdel-Kader K, Cai M, Yabes J, Shah N, Schell JO, Jhamb M. Implementation of Surprise Question Assessments using the Electronic Health Record in Older Adults with Advanced CKD. KIDNEY360 2021; 2:966-973. [PMID: 35373084 PMCID: PMC8791363 DOI: 10.34067/kid.0007062020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 04/01/2021] [Indexed: 12/12/2022]
Abstract
Background The Surprise Question (SQ; "Would you be surprised if this patient died in the next 12 months?") is a validated prognostication tool for mortality and hospitalization among patients with advanced CKD. Barriers in clinical workflows have slowed SQ implementation in practice. Objectives The aims of this study were: (1) to evaluate implementation outcomes after the use of electronic health record (EHR) decision support to automate the collection of the SQ; and (2) to assess the prognostic utility of the SQ for mortality and hospitalization/emergency room (ER) visits. Methods We developed and implemented a best practice alert (BPA) in the EHR to identify nephrology outpatients ≥60 years of age with an eGFR <30 ml/min per 1.73 m2. At appointment, the BPA prompted the physician to answer the SQ. We assessed the rate and timeliness of provider responses. We conducted a post-hoc open-ended survey to assess physician perceptions of SQ implementation. We assessed the SQ's prognostic utility in survival and time-to-hospital encounter (hospitalization/ER visit) analyses. Results Among 510 patients for whom the BPA triggered, 95 (19%) had the SQ completed by 16 physicians. Among those completed, nearly all (98%) were on appointment day, and 61 (64%) the first time the BPA fired. Providers answered "no" for 27 (28%) and "yes" for 68 (72%) patients. By 12 months, six (22%) "no" patients died; three (4%) "yes" patients died (hazard ratio [HR] 2.86, ref: yes, 95% CI, 1.06 to 7.69). About 35% of "no" patients and 32% of "yes" patients had a hospital encounter by 12 months (HR, 1.85, ref: yes, 95% CI, 0.93 to 3.69). Physicians noted (1) they had goals-of-care conversations unprompted; (2) EHR-based interventions alone for goals-of-care are ineffective; and (3) more robust engagement is necessary. Conclusions We successfully integrated the SQ into the EHR to aid in clinical practice. Additional implementation efforts are needed to encourage further integration of the SQ in clinical practice.
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Affiliation(s)
- Natalie C. Ernecoff
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Khaled Abdel-Kader
- Division of Nephrology and Hypertension, Vanderbilt University, Nashville, Tennessee
| | - Manqi Cai
- Department of Biostatistics, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jonathan Yabes
- Department of Biostatistics, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Nirav Shah
- Division of Renal and Electrolyte, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jane O. Schell
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Division of Renal and Electrolyte, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Manisha Jhamb
- Division of Renal and Electrolyte, University of Pittsburgh, Pittsburgh, Pennsylvania
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Assessing the Delivery of Coordinated Care to Patients with Advanced Chronic Kidney Disease in Ontario, Canada: A Survey of Patients and Healthcare Professionals. Int J Integr Care 2021; 21:30. [PMID: 34220394 PMCID: PMC8231462 DOI: 10.5334/ijic.5587] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Introduction: Patients with advanced Chronic Kidney Disease (CKD) have complex health needs, and thus require care that is coordinated across professionals and organizations. This study aimed to describe the extent of coordinated care delivery for patients with advanced CKD from the perspectives of both patients and healthcare professionals. Methods: The Coordination Scale of the Patient Assessment of Chronic Illness Care (PACIC-26) survey was administered to a random sample of 14,257 patients on maintenance dialysis or receiving care in end-stage kidney disease preparation clinics in Ontario, Canada. A five-item survey was administered to 596 multidisciplinary nephrology professionals. Results: Among the 1,925 patient respondents, 67% reported they had been referred to an allied health professional; 19% had been encouraged to attend programs in the community; and 34% had been told how their visits with other types of doctors helped their treatment (% reporting “always” or “most of the time”). Patient responses were significantly different by treatment modality/setting, but not by gender or geographic location of treatment facility. Among the 276 professional respondents, 37% reported their patients’ care was well-coordinated across settings; 56% reported participating in interdisciplinary care planning discussions; and 53% reported they are aware of appropriate home and community services to support their patients (% reporting “always” or “most of the time”). Conclusion: The results suggest that care for patients with advanced CKD in Ontario is not consistently coordinated. Healthcare professionals may enhance patient perceptions of coordinated care through explicit communication with patients about how the professionals they see and treatments or services they receive influence their overall health and well-being. At a systems level, there is a need to improve professional awareness of and linkages to home- and community-based services.
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11
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Menezes HFD, Camacho ACLF, Lins SMDSB, Campos TDS, Lima FR, Jales AKFA, Silva RARD. Terms of specialized nursing language for chronic renal patients undergoing conservative treatment. Rev Bras Enferm 2021; 73:e20190820. [PMID: 33338153 DOI: 10.1590/0034-7167-2019-0820] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 06/10/2020] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES to validate the terms of the specialized nursing language used in the care of people with chronic kidney disease undergoing conservative treatment identified in the literature by mapping them with terms of the International Classification for Nursing Practice, version 2019, and representing them by means of a mandala. METHODS descriptive, documentary and methodological study. The terms were collected in 53 scientific articles, standardized and mapped with the terminology. The validation was performed by six nurses through a focus group. The Content Validity Index was used and terms with a value ≥ 0.80 were validated. RESULTS the normalization resulted in 957 relevant terms, of which 499 were constant and 458 not included in the terminology. Terms were validated when Content Validity Index was between 0.86 and 1.0. CONCLUSIONS the study allowed the validation of terms that will contribute to unify the professional language of nursing in the care of people with chronic kidney disease.
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12
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Metzger M, Yoder J, Fitzgibbon K, Blackhall L, Abdel-Rahman E. Nephrology and Palliative Care Collaboration in the Care of Patients With Advanced Kidney Disease: Results of a Clinician Survey. Kidney Med 2021; 3:368-377.e1. [PMID: 34136783 PMCID: PMC8178464 DOI: 10.1016/j.xkme.2021.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Rationale & Objective Despite calls for integrating palliative care into chronic kidney disease (CKD) care, uptake remains low. The study aim was to describe clinicians’ perceptions of the clinical and research priorities in CKD care and the main barriers to collaboration. Study Design This was a descriptive cross-sectional study using an online survey developed by clinicians and researchers as the primary data collection method. Setting & Participants Clinicians in nephrology and palliative care departments (N = 195) at an academic health center in Virginia were invited to participate. Of the 48.7% (n = 95) who responded, most were registered nurses (65.3%) in nephrology (80%) with more than 15 years’ experience (40%). Predictors Factors including discipline (nursing, social work, and physician) and practice area (palliative care or nephrology) were assessed. Outcomes Main outcomes of interest included clinicians’ perceptions of the role of palliative care, barriers to collaboration, and the top clinical and research priorities for patients with advanced CKD. Analytic Approach Survey data were analyzed using SPSS using descriptive statistics. Results Respondents reported being comfortable caring for patients near the end of life and endorsed advance care planning and collaboration between nephrology and palliative care teams. However, both rarely happen. Fragmentation, or poor coordination of care, was perceived to be the main barrier to collaboration. Perceptions regarding collaboration facilitation differed; nephrology clinicians identified patient/family education as the most important facilitator while palliative care clinicians identified clinician education as most important. Top clinical priorities differed. Palliative care clinicians reported pain/symptom management as taking priority while nephrology clinicians identified caregiver/family support. Developing interventions to support treatment-related decision making was the top research priority. Limitations Results reflect perceptions of about half the clinicians at 1 academic health center. Conclusions Additional studies to capture patients’ and families’ perspectives and examine end-of-life care processes are needed. Results may inform future targeted interventions.
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Affiliation(s)
- Maureen Metzger
- University of Virginia School of Nursing, Charlottesville, VA
| | - Jonathan Yoder
- University of Virginia School of Nursing, Charlottesville, VA
| | - Kara Fitzgibbon
- Hemodialysis Unit and Home Hemodialysis Program, University of Virginia Health, University of Virginia School of Medicine, Charlottesville, VA
| | - Leslie Blackhall
- Weldon Cooper Center, Center for Survey Research, University of Virginia, Charlottesville, VA
| | - Emaad Abdel-Rahman
- Palliative Care Services, University of Virginia Health, University of Virginia School of Medicine, Charlottesville, VA
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Diamond LH, Armistead NC, Lupu DE, Moss AH. Recommendations for Public Policy Changes to Improve Supportive Care for Seriously Ill Patients With Kidney Disease. Am J Kidney Dis 2020; 77:529-537. [PMID: 33278476 DOI: 10.1053/j.ajkd.2020.09.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 09/29/2020] [Indexed: 01/03/2023]
Abstract
National and international nephrology organizations have identified substantial unmet supportive care needs of patients with kidney disease and issued recommendations. In the United States, the most recent comprehensive effort to change kidney care, the Advancing American Kidney Health Initiative, does not explicitly address supportive care needs, although it attempts to implement more patient-centered care. This Perspective from the leaders of the Coalition for Supportive Care of Kidney Patients advocates for urgent policy changes to improve patient-centered care and the quality of life of seriously ill patients with kidney disease. It argues for the provision of supportive care by an interdisciplinary team led by nephrology clinicians to improve shared decision-making, advance care planning, pain and symptom management, the explicit offering of active medical management without dialysis as an option for patients who may not benefit from dialysis, and the removal by the Centers for Medicare & Medicaid Services and all other payors of financial and regulatory disincentives to quality supportive care, including hospice, for patients with or approaching kidney failure. It also emphasizes that all educational and accreditation programs for nephrology clinicians include kidney supportive care and its essential role in the care of patients with kidney disease.
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Affiliation(s)
- Louis H Diamond
- Center for Aging, Health and Humanities, George Washington University School of Nursing, Washington, DC; Coalition for Supportive Care of Kidney Patients, Washington, DC
| | - Nancy C Armistead
- Center for Aging, Health and Humanities, George Washington University School of Nursing, Washington, DC; Coalition for Supportive Care of Kidney Patients, Washington, DC
| | - Dale E Lupu
- Center for Aging, Health and Humanities, George Washington University School of Nursing, Washington, DC; Coalition for Supportive Care of Kidney Patients, Washington, DC
| | - Alvin H Moss
- Coalition for Supportive Care of Kidney Patients, Washington, DC; Center for Health Ethics and Law, West Virginia University School of Medicine, Morgantown, WV.
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Tonelli M, Vanholder R, Himmelfarb J. Health Policy for Dialysis Care in Canada and the United States. Clin J Am Soc Nephrol 2020; 15:1669-1677. [PMID: 32586926 PMCID: PMC7646249 DOI: 10.2215/cjn.14961219] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Contemporary dialysis treatment for chronic kidney failure is complex, is associated with poor clinical outcomes, and leads to high health costs, all of which pose substantial policy challenges. Despite similar policy goals and universal access for their kidney failure programs, the United States and Canada have taken very different approaches to dealing with these challenges. While US dialysis care is primarily government funded and delivered predominantly by private for-profit providers, Canadian dialysis care is also government funded but delivered almost exclusively in public facilities. Differences also exist for regulatory mechanisms and the policy incentives that may influence the behavior of providers and facilities. These differences in health policy are associated with significant variation in clinical outcomes: mortality among patients on dialysis is consistently lower in Canada than in the United States, although the gap has narrowed in recent years. The observed heterogeneity in policy and outcomes offers important potential opportunities for each health system to learn from the other. This article compares and contrasts transnational dialysis-related health policies, focusing on key levers including payment, finance, regulation, and organization. We also describe how policy levers can incentivize favorable practice patterns to support high-quality/high-value, person-centered care and to catalyze the emergence of transformative technologies for alternative kidney replacement strategies.
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Affiliation(s)
- Marcello Tonelli
- Division of Nephrology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Raymond Vanholder
- Nephrology Section, Department of Internal Medicine, Ghent University Hospital, Ghent, Belgium, European Kidney Health Alliance
| | - Jonathan Himmelfarb
- Kidney Research Institute, School of Medicine, Seattle, Washington .,Division of Nephrology, Department of Medicine, University of Washington, Seattle, Washington
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Abdel-Rahman EM, Metzger M, Blackhall L, Asif M, Mamdouhi P, MacIntyre K, Casimir E, Ma JZ, Balogun RA. Association between Palliative Care Consultation and Advance Palliative Care Rates: A Descriptive Cohort Study in Patients at Various Stages in the Continuum of Chronic Kidney Disease. J Palliat Med 2020; 24:536-544. [PMID: 32996797 DOI: 10.1089/jpm.2020.0153] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
Background: Despite evidence that advance care planning (ACP) benefits patients with serious illnesses, there is a dearth of information about "who" is referred for palliative care (PC) consultation, the rate of PC consultation, and the outcomes of referrals in patients with advanced chronic kidney disease/end-stage kidney disease (aCKD/ESKD). Objectives: (1) To describe patient characteristics associated with PC consultations and (2) to determine the frequency and outcome of PC consultation on documented ACP discussions for patients with aCKD/ESKD. Methodology/Design: This is retrospective observational electronic health record cohort review. Settings: University of Virginia (UVA) hospital, clinics, and dialysis units. Participants: Patients were studied along two time intervals. Time period January 1, 2015 to June 30, 2017 included all patients admitted to UVA during that time period with estimated glomerular filtration rate (eGFR) <60 mL/minute. Time period January 1, 2018 to March 31, 2019 included two cohorts: patients with eGFR <15 mL/minute who had died during study period excluding those who withdrew from dialysis and those who were dialysis dependent and withdrew from dialysis. Results: Aside from higher rates of PC consultation in patients with heart failure, none of the demographic and comorbidity data studied affected whether or not a patient is referred to PC in patients with aCKD/ESKD. PC consultation rates were low among all patients studied: 14.7% in patients with eGFR <60 mL/minute, 28.9% in dialysis patients withdrawing from dialysis, and 57.1% in terminally ill patients with eGFR <15 mL/minute. In all cohorts, PC consultations were associated with improved ACP. Conclusion: PC consultation is significantly associated with better end-of-life outcomes with more completion of ACP and hospice referral in patients with aCKD/ESKD. PC consultation rates remain low. Even in terminally ill patients with more aCKD, >40% were never seen by PC. Until policies and curricula better prepare nephrologists to independently address ACP, collaboration between nephrologists and PC specialists is recommended.
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Affiliation(s)
| | - Maureen Metzger
- School of Nursing, University of Virginia, Charlottesville, Virginia, USA
| | - Leslie Blackhall
- Section of Palliative Medicine, University of Virginia, Charlottesville, Virginia, USA
| | - Mohammad Asif
- Mary Washington Health Care, Fredericksburg, Virginia, USA
| | | | - Kara MacIntyre
- School of Medicine, University of Virginia, Charlottesville, Virginia, USA
| | - Ernst Casimir
- School of Medicine, University of Virginia, Charlottesville, Virginia, USA
| | - Jennie Z Ma
- Public Health Sciences, University of Virginia, Charlottesville, Virginia, USA
| | - Rasheed A Balogun
- Division of Nephrology, University of Virginia, Charlottesville, Virginia, USA
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16
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Fulton AT, Richman K, Azar M, Sanzen K, Devine J, Ferrone C, Tanzer JR, Lally K. A Novel Interprofessional Palliative Care and Geriatrics Curriculum for Nephrology Teams. Am J Hosp Palliat Care 2020; 37:913-917. [DOI: 10.1177/1049909120915462] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Background: The population of older adults with chronic kidney disease (CKD) is increasing and nephrologists need education on the principles of geriatrics and palliative care to effectively care for this population. Objectives: Our objective was to develop and deliver a curriculum to interprofessional clinicians caring for older adults with CKD. The aim of this curriculum would be to improve knowledge of the principles of geriatrics and palliative care. Design: We have previously developed a curriculum on geriatrics and palliative care targeted toward primary care teams. In this project, we used an interdisciplinary steering committee to modify the curriculum for nephrology teams. Setting: This curriculum was delivered in a live grand rounds setting and was recorded and made available via online platform for virtual learning. Participants: The 6-session curriculum was delivered to 611 live and online learners between January 2018 and April 2019, with more than half of the participants (n = 317) completing more than 1 session. Participants came from a variety of disciplines including medicine, nursing, pharmacy, and social work. Results: Participants had a high rate of agreement with the statement that the curriculum met learning objectives, with live participants having stronger agreement. Participants reported that the activity would change their practice behavior by calling palliative care earlier, as well as improving their communication skills. Conclusion: Interprofessional collaboration can result in improved learning around the management of patients with CKD or end-stage kidney disease.
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Affiliation(s)
- Ana Tuya Fulton
- Geriatrics & Palliative Care, Care New England Health System, Providence, RI, USA
- The Warren Alpert School of Medicine, Brown University, Providence, RI, USA
- Integra Community Care Network, LLC, Providence, RI, USA
| | - Katherine Richman
- Geriatrics & Palliative Care, Care New England Health System, Providence, RI, USA
- Providence VA Medical Center, Lifespan, Providence, RI, USA
| | - Maroun Azar
- Geriatrics & Palliative Care, Care New England Health System, Providence, RI, USA
- Brown Medicine, Inc, Providence, RI, USA
| | - Kelley Sanzen
- The Warren Alpert School of Medicine, Brown University, Providence, RI, USA
- Brown Medicine, Inc, Providence, RI, USA
| | | | - Christine Ferrone
- Rhode Island Geriatric Education Center, University of Rhode Island, Kingston, RI, USA
| | - Joshua Ray Tanzer
- Rhode Island Geriatric Education Center, University of Rhode Island, Kingston, RI, USA
| | - Kate Lally
- Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
- Harvard Medical School, Harvard University, Boston, MA, USA
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Hasson F, Nicholson E, Muldrew D, Bamidele O, Payne S, McIlfatrick S. International palliative care research priorities: A systematic review. BMC Palliat Care 2020; 19:16. [PMID: 32013949 PMCID: PMC6998205 DOI: 10.1186/s12904-020-0520-8] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Accepted: 01/17/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There has been increasing evidence and debate on palliative care research priorities and the international research agenda. To date, however, there is a lack of synthesis of this evidence, examining commonalities, differences, and gaps. To identify and synthesize literature on international palliative care research priorities originating from Western countries mapped to a quality assessment framework. METHODS A systematic review of several academic and grey databases were searched from January 2008-June 2019 for studies eliciting research priorities in palliative care in English. Two researchers independently reviewed, critically appraised, and conducted data extraction and synthesis. RESULTS The search yielded 10,235 articles (academic databases, n = 4108; grey literature, n = 6127), of which ten were included for appraisal and review. Priority areas were identified: service models; continuity of care; training and education; inequality; communication; living well and independently; and recognising family/carer needs and the importance of families. Methodological approaches and process of reporting varied. There was little representation of patient and caregiver driven agendas. The priorities were mapped to the Donabedian framework for assessing quality reflecting structure, process and outcomes and key priority areas. CONCLUSIONS Limited evidence exists pertaining to research priorities across palliative care. Whilst a broad range of topics were elicited, approaches and samples varied questioning the credibility of findings. The voice of the care provider dominated, calling for more inclusive means to capture the patient and family voice. The findings of this study may serve as a template to understand the commonalities of research, identify gaps, and extend the palliative care research agenda.
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Affiliation(s)
- Felicity Hasson
- Institute of Nursing and Health Research, School of Nursing, Ulster University, Shore Road, Newtownabbey, BT37 0QB, Northern Ireland.
| | - Emma Nicholson
- UCD School of Nursing, Midwifery and Health Systems, UCD College of Health and Agricultural Sciences, University College Dublin, Belfield, Dublin 4, Ireland
| | - Deborah Muldrew
- Institute of Nursing and Health Research, School of Nursing, Ulster University, Shore Road, Newtownabbey, BT37 0QB, Northern Ireland
| | - Olufikayo Bamidele
- Academcy of Primary Care, Hull York Medical School, Allam Medical Building, University of Hull, Hull, HU6 7RZ, England
| | - Sheila Payne
- International Observatory on End of Life Care, Lancaster University, LA14YX, Lancaster, UK
| | - Sonja McIlfatrick
- Institute of Nursing and Health Research, School of Nursing, Ulster University, Shore Road, Newtownabbey, BT37 0QB, Northern Ireland
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18
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Wong SPY, Boyapati S, Engelberg RA, Thorsteinsdottir B, Taylor JS, O'Hare AM. Experiences of US Nephrologists in the Delivery of Conservative Care to Patients With Advanced Kidney Disease: A National Qualitative Study. Am J Kidney Dis 2020; 75:167-176. [PMID: 31570175 PMCID: PMC7012760 DOI: 10.1053/j.ajkd.2019.07.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 07/05/2019] [Indexed: 11/11/2022]
Abstract
RATIONALE & OBJECTIVE It is relatively unusual for US patients with advanced chronic kidney disease (CKD) to forgo initiation of maintenance dialysis. Our objective was to describe practice approaches of US nephrologists who have provided conservative care for members of this population. STUDY DESIGN Qualitative study using semi-structured interviews. SETTING & PARTICIPANTS A national sample of 21 nephrologists experienced in caring for patients with advanced CKD who decided not to start dialysis. ANALYTICAL APPROACH Grounded theory methods to identify dominant themes reflecting nephrologists' experiences with and approaches to conservative care for patients with advanced CKD. RESULTS Nephrologists who participated in this study were primarily from academic practices (n=14) and urban areas (n=15). Two prominent themes emerged from qualitative analysis reflecting nephrologists' experiences with and approaches to conservative care: (1) person-centered practices, which described a holistic approach to care that included basing treatment decisions on what mattered most to individual patients, framing dialysis as an explicit choice, being mindful of sources of bias in medical decision making, and being flexible to the changing needs, values, and preferences of patients; and (2) improvising a care infrastructure, which described the challenges of managing patients conservatively within health systems that are not optimally configured to support their needs. Participating nephrologists described cobbling together resources, assuming a range of different health care roles, preparing patients to navigate health systems in which initiation of dialysis served as a powerful default, and championing the principles of conservative care among their colleagues. LIMITATIONS The themes identified likely are not generalizable to most US nephrologists. CONCLUSIONS Insights from a select group of US nephrologists who are early adopters of conservative care signal the need for a stronger cultural and health system commitment to building care models capable of supporting patients who choose to forgo dialysis.
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Affiliation(s)
- Susan P Y Wong
- Kidney Research Institute, University of Washington, Seattle, WA; Health Services Research and Development Center, VA Puget Sound Health Care System, Seattle, WA; Division of Nephrology, University of Washington, Seattle, WA.
| | | | - Ruth A Engelberg
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA
| | | | - Janelle S Taylor
- Department of Anthropology, University of Washington, Seattle, WA
| | - Ann M O'Hare
- Kidney Research Institute, University of Washington, Seattle, WA; Health Services Research and Development Center, VA Puget Sound Health Care System, Seattle, WA; Division of Nephrology, University of Washington, Seattle, WA
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19
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Abstract
Rationale & Objective Understanding whether family members’ experiences with patients’ treatment for end-stage kidney disease (ESKD) were expected could guide the development of family-centered interventions that enhance the preparedness of patients and their care partners for kidney replacement therapies. We explored unexpected negative experiences with ESKD treatments among family members of dialysis and posttransplantation patients to identify meaningful directions for family-centered research and clinical care. Study Design Qualitative study. Setting & Participants 8 focus groups comprising 49 family members of dialysis patients and living donor kidney transplant recipients undergoing medical care in Baltimore, MD. Analytical Approach Focus groups were stratified by patients’ treatment (in-center hemodialysis, home hemodialysis, peritoneal dialysis, or living donor kidney transplantation) and family members’ self-reported race (African American vs non–African American), resulting in 2 groups per treatment experience. Inductive thematic analysis was used to identify themes in focus group transcripts. Themes shared across different treatment groups were highlighted to provide insight into common experiences. Results We identified 4 themes that described family members’ unexpected negative treatment experiences: becoming a care partner (unanticipated responsibilities and sleep disruptions), adverse psychological treatment responses in patients (eg, depression) and family members (eg, anxiety), treatment delivery and logistics (insufficient information, medication regimen, and logistical inconveniences), and patient morbidity (dialysis-related health problems and fatigue). All themes were relevant to discussions in the in-center hemodialysis, peritoneal dialysis, and transplantation groups, whereas psychological responses and morbidity themes did not reflect discussions in home hemodialysis groups. Limitations Data collection occurred from 2008 to 2009; family members were recruited through patients undergoing care in 1 geographic area; 1 family member participant per patient. Conclusions Family members described a broad range of unexpected negative experiences with ESKD treatments. Efforts to prepare families for ESKD treatments through more family-centered care, early and tailored education, and interventions targeting care partner preparedness, health provider–family member communication, and relationship dynamics in family member–patient dyads are needed.
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Morrison RS, Aldridge MD, Block J, Chiu L, Maroney C, Morrison CA, Meier DE. The National Palliative Care Research Center: Ten Years of Promoting and Developing Research in Palliative Care. J Palliat Med 2018; 21:1548-1557. [PMID: 30136886 DOI: 10.1089/jpm.2018.0204] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The evidence base to support high-quality clinical care and number of scientists available to develop this evidence base are inadequate. OBJECTIVE To describe the first 10 years of the National Palliative Care Research Center's (NPCRC) programs and their outcomes. DESIGN Established in 2005, NPCRC was created in direct response to the recommendations of the Institute of Medicine. Specifically, NPCRC was created to expand the palliative care evidence-based needed for both health policy and clinical practice by supporting research scientists, stimulating research and innovation, and creating a community of researchers focused on the needs of persons with serious illness and their families. MEASUREMENTS Subsequent grant funding following NPCRC investment (web searches of NIH Research Portfolio Online Reporting Tools [RePORT], Veterans Administration and Patient Centered Outcomes Research Institute [PCORI] grant databases, grantee on-line surveys, and grantee annual reports) promotions (grantee on-line surveys and annual reports), publications (PubMed searches), and NPCRC participant satisfaction (grantee questionnaires). RESULTS As of July 2017, NPCRC has funded 47 junior investigators representing over 10 disciplines. These investigators have leveraged NPCRC's $7.8 million investment into 52 federal grants totaling $74.8 million dollars and 69 foundation grants totaling $16 million. Thirty-five grants ($5.8 million) have been awarded to experienced investigators, resulting in additional grant funding of $104.5 million dollars ($78.5 million federal, $26 million nonfederal). Satisfaction with NPCRC's program has been uniformly high and policy efforts have resulted in enhanced federal funding opportunities in palliative care research. CONCLUSIONS NPCRC's focus on people and infrastructure in conjunction with a top-down bottom-up strategy has been critical in improving the palliative care evidence base.
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Affiliation(s)
- R Sean Morrison
- 1 National Palliative Care Research Center of the Brookdale Department of Geriatrics and Palliative Medicine , Icahn School of Medicine at Mount Sinai, New York, New York
| | - Melissa D Aldridge
- 1 National Palliative Care Research Center of the Brookdale Department of Geriatrics and Palliative Medicine , Icahn School of Medicine at Mount Sinai, New York, New York
| | - James Block
- 1 National Palliative Care Research Center of the Brookdale Department of Geriatrics and Palliative Medicine , Icahn School of Medicine at Mount Sinai, New York, New York.,2 Center to Advance Palliative Care of the Brookdale Department of Geriatrics and Palliative Medicine , Icahn School of Medicine at Mount Sinai, New York, New York
| | - Lily Chiu
- 1 National Palliative Care Research Center of the Brookdale Department of Geriatrics and Palliative Medicine , Icahn School of Medicine at Mount Sinai, New York, New York
| | - Catherine Maroney
- 1 National Palliative Care Research Center of the Brookdale Department of Geriatrics and Palliative Medicine , Icahn School of Medicine at Mount Sinai, New York, New York
| | - Corey A Morrison
- 1 National Palliative Care Research Center of the Brookdale Department of Geriatrics and Palliative Medicine , Icahn School of Medicine at Mount Sinai, New York, New York.,3 Brown University School of Public Health , Providence, Rhode Island
| | - Diane E Meier
- 2 Center to Advance Palliative Care of the Brookdale Department of Geriatrics and Palliative Medicine , Icahn School of Medicine at Mount Sinai, New York, New York
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Tang W, Chen Q, Chen L, Chen S, Shao X, Wang X. FAVORABLE EFFECT OF LEVOTHYROXINE ON NUTRITIONAL STATUS OF PATIENTS WITH STAGE 3-4 CHRONIC KIDNEY DISEASE. ACTA ENDOCRINOLOGICA (BUCHAREST, ROMANIA : 2005) 2018; 14:338-345. [PMID: 31149281 PMCID: PMC6525772 DOI: 10.4183/aeb.2018.338] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The aim of this study was to analyze the incidence of malnutrition in patients with stage 3-4 chronic kidney disease (CKD) and primary subclinical hypothyroidism and the effect of levothyroxine for improving nutritional status and delaying kidney disease. PATIENTS AND METHODS In the study were included 200 patients with stage 3-4 CKD: CKD3 stage group (n=100) and CKD4 stage group (n=100). These patients were further divided into: control group (non-treatment group) group a (n=65) and experiment group (treatment group) group b (n=135) according to their levothyroxine treatment. The CKD3 stage group is divided into c3 (n=35) and e3 (n=65), and CKD4 group is divided into c4 (n=30) and e4 (n=70) groups. RESULTS Upon treatment of subclinical hypothyroidism with levothyroxine, nutritional indicators of patients are improved, and the weight, left and right-hand grip strength, hemoglobin (HB), serum albumin are higher compared to control. After levothyroxine treatment, eGFR in the treatment group increased with each time point, while in the control group it could be seen a significant decrease. This effect was more robust in the CKD3 group than in the CKD4 group. In conclusion, levothyroxine treatment can delay the progression of kidney diseases with more efficacy in stage 3 patients.
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Affiliation(s)
- W. Tang
- The First People’s Hospital of Fuyang - Intensive care unit, Hangzhou, Zhejiang, China
| | - Q. Chen
- The First People’s Hospital of Fuyang - Intensive care unit, Hangzhou, Zhejiang, China
| | - L. Chen
- The First People’s Hospital of Fuyang - Intensive care unit, Hangzhou, Zhejiang, China
| | - S. Chen
- The First People’s Hospital of Fuyang - Intensive care unit, Hangzhou, Zhejiang, China
| | - X. Shao
- The First People’s Hospital of Fuyang - Intensive care unit, Hangzhou, Zhejiang, China
| | - X. Wang
- The First People’s Hospital of Fuyang - Intensive care unit, Hangzhou, Zhejiang, China
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22
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Chambers S, Healy H, Hoy WE, Kark A, Ratanjee S, Mitchell G, Douglas C, Yates P, Bonner A. Health service utilisation during the last year of life: a prospective, longitudinal study of the pathways of patients with chronic kidney disease stages 3-5. BMC Palliat Care 2018; 17:57. [PMID: 29622009 PMCID: PMC5887240 DOI: 10.1186/s12904-018-0310-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2018] [Accepted: 03/21/2018] [Indexed: 12/22/2022] Open
Abstract
Background Chronic kidney disease (CKD) is a growing global problem affecting around 10% of many countries’ populations. Providing appropriate palliative care services (PCS) to those with advanced kidney disease is becoming paramount. Palliative/supportive care alongside usual CKD clinical treatment is gaining acceptance in nephrology services although the collaboration with and use of PCS is not consistent. Methods The goal of this study was to track and quantify the health service utilisation of people with CKD stages 3-5 over the last 12 months of life. Patients were recruited from a kidney health service (Queensland, Australia) for this prospective, longitudinal study. Data were collected for 12 months (or until death, whichever was sooner) during 2015-17 from administrative health sources. Emergency department presentations (EDP) and inpatient admissions (IPA) (collectively referred to as critical events) were reviewed by two Nephrologists to gauge if the events were avoidable. Results Participants (n = 19) with a median age of 78 years (range 42-90), were mostly male (63%), 79% had CKD stage 5, and were heavy users of health services during the study period. Fifteen patients (79%) collectively recorded 44 EDP; 61% occurred after-hours, 91% were triaged as imminently and potentially life-threatening and 73% were admitted. Seventy-four IPA were collectively recorded across 16 patients (84%); 14% occurred on weekends or public holidays. Median length of stay was 3 days (range 1-29). The median number of EDP and IPA per patient was 1 and 2 (range 0-12 and 0-20) respectively. The most common trigger to both EDP (30%) and IPA (15%) was respiratory distress. By study end 37% of patients died, 63% were known to PCS and 11% rejected a referral to a PCS. All critical events were deemed unavoidable. Conclusions Few patients avoided using acute health care services in a 12 month period, highlighting the high service needs of this cohort throughout the long, slow decline of CKD. Proactive end-of-life care earlier in the disease trajectory through integrating renal and palliative care teams may avoid acute presentations to hospital through better symptom management and planned care pathways.
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Affiliation(s)
- Shirley Chambers
- Faculty of Health, Queensland University of Technology, Brisbane, Australia. .,National Health and Medical Research Council, Centre for Research Excellence in End of Life Care, Brisbane, Australia.
| | - Helen Healy
- Kidney Health Service, Metro North Hospital and Health Service, Queensland Health, Brisbane, Australia.,National Health and Medical Research Council, Chronic Kidney Disease Centre for Research Excellence, Brisbane, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Wendy E Hoy
- National Health and Medical Research Council, Chronic Kidney Disease Centre for Research Excellence, Brisbane, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Adrian Kark
- Kidney Health Service, Metro North Hospital and Health Service, Queensland Health, Brisbane, Australia
| | - Sharad Ratanjee
- Kidney Health Service, Metro North Hospital and Health Service, Queensland Health, Brisbane, Australia
| | - Geoffrey Mitchell
- National Health and Medical Research Council, Centre for Research Excellence in End of Life Care, Brisbane, Australia.,National Health and Medical Research Council, Chronic Kidney Disease Centre for Research Excellence, Brisbane, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Carol Douglas
- Palliative Care Service, Royal Brisbane and Women's Hospital, Queensland Health, Brisbane, Australia
| | - Patsy Yates
- Faculty of Health, Queensland University of Technology, Brisbane, Australia.,National Health and Medical Research Council, Centre for Research Excellence in End of Life Care, Brisbane, Australia.,Centre for Palliative Care Research and Education, Queensland Health, Brisbane, Australia
| | - Ann Bonner
- Faculty of Health, Queensland University of Technology, Brisbane, Australia.,National Health and Medical Research Council, Centre for Research Excellence in End of Life Care, Brisbane, Australia.,Kidney Health Service, Metro North Hospital and Health Service, Queensland Health, Brisbane, Australia.,National Health and Medical Research Council, Chronic Kidney Disease Centre for Research Excellence, Brisbane, Australia
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23
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Kurella Tamura M, O'Hare AM, Lin E, Holdsworth LM, Malcolm E, Moss AH. Palliative Care Disincentives in CKD: Changing Policy to Improve CKD Care. Am J Kidney Dis 2018; 71:866-873. [PMID: 29510920 DOI: 10.1053/j.ajkd.2017.12.017] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 12/14/2017] [Indexed: 01/03/2023]
Abstract
The dominant health delivery model for advanced chronic kidney disease (CKD) and end-stage renal disease (ESRD) in the United States, which focuses on provision of dialysis, is ill-equipped to address many of the needs of seriously ill patients. Although palliative care may address some of these gaps in care, its integration into advanced CKD care has been suboptimal due to several health system barriers. These barriers include uneven access to specialty palliative care services, underdeveloped models of care for seriously ill patients with advanced CKD, and misaligned policy incentives. This article reviews policies that affect the delivery of palliative care for this population, discusses reforms that could address disincentives to palliative care, identifies quality measurement issues for palliative care for individuals with advanced CKD and ESRD, and considers potential pitfalls in the implementation of new models of integrated palliative care. Reforming health care delivery in ways that remove policy disincentives to palliative care for patients with advanced CKD and ESRD will fill a critical gap in care.
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Affiliation(s)
- Manjula Kurella Tamura
- Geriatric Research and Education Clinical Center, VA Palo Alto Health Care System, Palo Alto, CA; Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA.
| | - Ann M O'Hare
- Division of Nephrology, University of Washington School of Medicine and VA Puget Sound Healthcare System, Seattle, WA
| | - Eugene Lin
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA; Centers for Health Policy, Stanford University School of Medicine, Palo Alto, CA; Primary Care Outcomes Research, Stanford University School of Medicine, Palo Alto, CA
| | - Laura M Holdsworth
- Division of Primary Care and Population Health, Stanford University School of Medicine, Palo Alto, CA
| | - Elizabeth Malcolm
- Division of Primary Care and Population Health, Stanford University School of Medicine, Palo Alto, CA
| | - Alvin H Moss
- Sections of Nephrology, West Virginia University School of Medicine, Morgantown, WV; Supportive Care, West Virginia University School of Medicine, Morgantown, WV
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24
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Walton LS, Shumer GD, Thorsteinsdottir B, Suh T, Swetz KM. Palliation Versus Dialysis for End-Stage Renal Disease in the Oldest Old: What are the Considerations? Palliat Care 2017; 10:1178224217735083. [PMID: 29051704 PMCID: PMC5638155 DOI: 10.1177/1178224217735083] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Accepted: 09/09/2017] [Indexed: 12/05/2022] Open
Abstract
As the US population continues to age, new cases of end-stage renal disease (ESRD) in individuals, aged 85 years or older (the oldest old), are increasing. Many patients who begin hemodialysis despite questionable benefit may struggle with high symptom burden and rapid functional decline. This article reviews the history regarding the funding and development of the Medicare ESRD program, reviews current approaches to the oldest old with ESRD, and considers strategies to improve the management approach of this vulnerable population.
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Affiliation(s)
- Lyle S Walton
- Department of Medicine, University of Michigan, Ann Arbor, MI, USA
- Department of Medicine, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Lyle S Walton, Section of Palliative Care, Birmingham VA Medical Center, 700 19th Street South, Birmingham, AL 35223, USA.
| | - Gregory D Shumer
- Department of Family Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Björg Thorsteinsdottir
- Department of Medicine, Mayo Clinic, Rochester, MN, USA
- Division of Primary Care Internal Medicine, Mayo Clinic, Rochester, MN, USA
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery and Bioethics Research Program, Mayo Clinic, Rochester, MN, USA
| | - Theodore Suh
- Department of Medicine, University of Michigan, Ann Arbor, MI, USA
- Department of Medicine, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Keith M Swetz
- Department of Medicine, The University of Alabama at Birmingham, Birmingham, AL, USA
- Section of Palliative Care, Birmingham VA Medical Center, Birmingham, AL, USA
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