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Buur LE, Bekker HL, Søndergaard H, Kannegaard M, Madsen JK, Khatir DS, Finderup J. Feasibility and acceptability of the ShareD dEciSIon making for patients with kidney failuRE to improve end-of-life care intervention: A pilot multicentre randomised controlled trial. INTERNATIONAL JOURNAL OF NURSING STUDIES ADVANCES 2024; 7:100231. [PMID: 39221228 PMCID: PMC11363568 DOI: 10.1016/j.ijnsa.2024.100231] [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] [Received: 03/02/2024] [Revised: 07/27/2024] [Accepted: 08/01/2024] [Indexed: 09/04/2024] Open
Abstract
Background Kidney failure is associated with a high disease burden and high mortality rates. National and international guidelines recommend health professionals involve patients with kidney failure in making decisions about end-of-life care, but implementation of these conversations within kidney services varies. We developed the DESIRE (ShareD dEciSIon-making for patients with kidney failuRE to improve end-of-life care) intervention from our studies investigating multiple decision maker needs and experiences of end-of-life care in kidney services. The DESIRE intervention's three components are a training programme for health professionals, a patient decision aid, and a kidney service consultation held to facilitate shared decision-making conversations about planning end-of-life care. Objectives To assess the feasibility and acceptability of integrating the DESIRE intervention within kidney services. Design A pilot study using a multicentre randomised controlled design. Setting Four Danish nephrology departments. Participants Patients with kidney failure who were 75 years of age or above, their relatives, and health professionals. Methods Patients were randomised to either the intervention or usual care. Feasibility data regarding delivering the intervention, the trial design, and outcome measures were collected through questionnaires and audio recordings at four points in time: before, during, post, and 3 months after the intervention. Acceptability data were collected through semi-structured interviews with patients and relatives, as well as a focus group with health professionals post the intervention. Results Twenty-seven patients out of the 32 planned were randomised either to the intervention (n= 14) or usual care (n= 13). In addition, four relatives and 12 health professionals participated. Follow-up was completed by 81 % (n= 22) of patient participants. We found that both feasibility and acceptability data suggested health professionals improved their decision support and shared decision-making skills via the training. Patient and relative participants experienced the intervention as supporting a shared decision-making process; from audio recordings, we showed health professionals were able to support proactively decision-making about end-of-life care within these consultations. All stakeholders perceived the intervention to be effective in promoting shared decision-making and relevant for supporting end-of-life care planning. Conclusions Participant feedback indicated that the DESIRE intervention can be integrated into practice to support patients, relatives, and health professionals in planning end-of-life care alongside the management of worsening kidney failure. Minimising exhaustion and enhancing engagement with the intervention should be a focus for subsequent refinement of the intervention. Registration The study has been registered at ClinicalTrials.gov with the identifier: NCT05842772. Date of first recruitment: March 20, 2023.
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Affiliation(s)
- Louise Engelbrecht Buur
- Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark
- Research Centre for Patient Involvement (ResCenPI), Aarhus University, Aarhus, Denmark
- Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Hilary Louise Bekker
- Research Centre for Patient Involvement (ResCenPI), Aarhus University, Aarhus, Denmark
- Department of Public Health, Aarhus University, Aarhus, Denmark
- Leeds Unit of Complex Intervention Development (LUCID), Leeds Institute of Health Science, School of Medicine, University of Leeds, Leeds, UK
| | | | | | | | - Dinah Sherzad Khatir
- Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Jeanette Finderup
- Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark
- Research Centre for Patient Involvement (ResCenPI), Aarhus University, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Winterbottom A, Hurst H, Murtagh FE, Bekker HL, Ormandy P, Hole B, Russon L, Murphy E, Bucknall K, Mooney A. Development of a Resource for Health Professionals to Raise Advance Care Planning Topics During Kidney Care Consultations: A Multiple User-Centered Design. Kidney Med 2024; 6:100874. [PMID: 39211348 PMCID: PMC11359737 DOI: 10.1016/j.xkme.2024.100874] [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] [Indexed: 09/04/2024] Open
Abstract
Rationale & Objective Planning and delivering treatment pathways that integrate end-of-life care, frailty assessment, and enhanced supportive care is a service priority. Despite this, people with kidney failure are less likely to have an advance care plan and receive hospice and palliative care compared with other chronic illness populations. This is linked to health professionals feeling unskilled initiating conversations around future treatment and care options. This article describes research underpinning the development of a guide for kidney health professionals discussing end-of-life and advance care planning options with people with kidney failure and family members. Study Design The study comprised 2 parts: an initial cross-sectional qualitative approach using in-depth interviews with older adults with kidney failure and (bereaved) carers followed by resource development with input from multiple stakeholders. Setting & Participants Older adults with kidney failure and (bereaved) carers recruited from 2 renal units in the North of England and by online advertisements with national United Kingdom-based kidney patient charities. Resource development included input from co-applicants, independent advisory committee, patient and public involvement team, multidisciplinary health professionals and academics in the United Kingdom and Denmark. Analytical Approach Thematic analysis was used to analyze the data. Results Twenty-seven people were interviewed: older adults with kidney failure (n = 18), carers (n = 5), bereaved carers (n = 4). Five themes are described: the context within which end-of-life conversations take place, preferences for end-of-life treatment and care, family members' role and needs in supporting people with kidney failure at the end-of-life, expectations and experience of dialysis treatment, and beliefs and experiences of death and dying. Limitations Participants were mainly White, British, and receiving hemodialysis. Conclusions People with (lived) experience of kidney failure informed a guide which aims to build on health professionals existing skills and improve confidence having conversations about future treatment and care. Kidney teams have expressed interest implementing the guide in practice and within their broader communications training packages.
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Key Words
- Advance care planning (personalized care planning, anticipatory care)
- end-of-life care
- health care professionals (renal physicians, clinicians, kidney doctors, nephrologists, dialysis nurses, renal nurses, kidney nurses, nephrology nurses)
- kidney failure (advanced kidney disease, end-stage kidney failure, end-stage kidney disease, chronic kidney disease)
- palliative care (palliative treatment, hospice care)
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Affiliation(s)
- Anna Winterbottom
- Leeds Renal Unit, Leeds Teaching Hospitals NHS Trust & Institute of Health Sciences, School of Medicine, University of Leeds, Leeds, UK
| | - Helen Hurst
- School of Health and Society, University of Salford and Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - Fliss E.M. Murtagh
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Hilary L. Bekker
- Institute of Health Sciences, School of Medicine, University of Leeds, Leeds, UK
| | - Paula Ormandy
- School of Health and Society, University of Salford, Salford, UK
| | - Barnaby Hole
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK and North Bristol NHS Foundation Trust, Southmead Hospital, Bristol, UK
| | - Lynne Russon
- Leeds Renal Unit, Leeds Teaching Hospitals NHS Trust and Wheatfields Hospice, Leeds, UK
| | - Emma Murphy
- University Hospitals Coventry and Warwickshire NHS Trust, Centre for Care Excellence, and Coventry University, Coventry, UK
| | - Keith Bucknall
- Patient and Public Involvement chair - lay member; kidney transplant recipient
| | - Andrew Mooney
- Leeds Renal Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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Wallin JM, Jacobson SH, Axelsson L, Lindberg J, Persson CI, Stenberg J, Wennman-Larsen A. The Surprise Question and Health-Related Quality of Life in Patients on Hemodialysis: A Cross-Sectional Multicenter Study. Palliat Med Rep 2024; 5:306-315. [PMID: 39144133 PMCID: PMC11319855 DOI: 10.1089/pmr.2023.0093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/17/2024] [Indexed: 08/16/2024] Open
Abstract
Background The Surprise Question (SQ) is a common method aimed at identifying frail patients who need serious illness conversations to integrate a palliative approach. However, little is known about whether the SQ identifies patients on hemodialysis who perceive that they are declining or have low health-related quality of life (HRQoL)-important aspects when considering the need for serious illness conversations. Objective To explore how nurses and physicians' responses to the SQ are associated with patients' self-reported HRQoL. Design Cross-sectional study. Subjects In total, 282 patients on hemodialysis were included. Measurements One nurse and one physician responded to the SQ for each patient. The patient-reported HRQoL was measured with the RAND 36-Item Health Survey 1.0 (RAND-36) and the EuroQual vertical visual analogue scale (EQ-VAS) from the EuroQual-5 Dimension Questionnaire (EQ-5D). Results Nurses' responses "no, not surprised" to the SQ were associated with patient-reported worsened health compared to one year ago (RAND-36), and lower perceived overall health (EQ-VAS). Physicians' responses "no, not surprised" were associated with lower overall health and lower physical functioning. Patient-reported pain, general health, fatigue, and emotional and social aspects were not associated with responses to the SQ. Conclusions The findings indicate that the SQ identifies patients on hemodialysis who report low overall health and low physical functioning. However, the SQ did not identify patients who reported pain, emotional problems, or fatigue, which are also important aspects to consider in identifying needs for serious illness conversations, symptom management, and to be able to integrate a palliative approach.
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Affiliation(s)
- Jeanette M. Wallin
- Department of Nursing Science, Sophiahemmet University, Stockholm, Sweden
- Division of Nephrology, Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
| | - Stefan H. Jacobson
- Division of Nephrology, Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
| | - Lena Axelsson
- Department of Nursing Science, Sophiahemmet University, Stockholm, Sweden
| | - Jenny Lindberg
- Department of Clinical Sciences, Unit of Medical Ethics, Lund University, Lund, Sweden
| | | | - Jenny Stenberg
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Agneta Wennman-Larsen
- Department of Nursing Science, Sophiahemmet University, Stockholm, Sweden
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
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Buur LE, Bekker HL, Søndergaard H, Kannegaard M, Madsen JK, Khatir DS, Finderup J. Shared decision making for patients with kidney failure to improve end-of-life care: Development of the DESIRE intervention. J Clin Nurs 2024; 33:3498-3512. [PMID: 38716825 DOI: 10.1111/jocn.17209] [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: 02/06/2024] [Revised: 04/07/2024] [Accepted: 04/28/2024] [Indexed: 08/09/2024]
Abstract
AIM To describe the development of a shared decision making intervention for planning end-of-life care for patients with kidney failure, their relatives and health professionals in kidney services. BACKGROUND End-of-life care conversations within standard disease management consultations are challenging for patients with kidney failure, their relatives and health professionals. End-of-life care planning is about making difficult decisions in advance, which is why health professionals need shared decision making skills to be able to initiate end-of-life conversations. Health professionals report needing more skills to raise the issue of end-of-life care options within consultations and patients want to be able to discuss issues important to them about future care plans. METHODS The development design was guided by the UK Medical Research Council's framework and a user-centred approach was applied. Four workshops were conducted with end users. The Template for Intervention Description and Replication for Population Health and Policy interventions was used to shape which questions needed to be answered through the workshops and to present the intervention. The International Patient Decision Aid Standards (IPDAS) criteria set the standards to be achieved. RESULTS Areas considered significant to a shared decision making intervention were training of health professionals, conversations about end-of-life care, planning and evaluation of the decisions, reporting decisions in health records and repetition of consultation. The development process went through 14 iterations. CONCLUSION An intervention named DESIRE was developed that comprises: (1) a training programme for health professionals; (2) shared decision making conversations; and (3) a patient decision aid. The intervention met 30 out of 33 IPDAS criteria. IMPLICATIONS FOR PRACTICE DESIRE is intended to support shared decision making about planning end-of-life care among patients with kidney failure, their relatives and health professionals. The study provides important tools for the stakeholders engaged that can be used within different models of care. IMPACT What problem did the study address? International guidelines recommend health professionals involve patients with kidney failure in making decisions about end-of-life care, but there is variation in how this is implemented within and across kidney services. Furthermore, patients, relatives and health professionals find it challenging to initiate conversations about end-of-life care. What were the main findings? The study resulted in the development of a complex intervention, called DESIRE, about shared decision making and planning end-of-life care for patients with kidney failure, their relatives and health professionals in kidney services, including a training programme for health professionals, shared decision making conversations and a patient decision aid. Where and on whom will the research have an impact? The research contributes a shared decision making intervention to patients in the later stage of kidney failure, their relatives and health professionals. We believe that the DESIRE intervention could be introduced during consultations with health professionals at an earlier stage of the patient's illness trajectory, as well as being applied to other chronic diseases. REPORTING METHOD This intervention development research is reported according to the GUIDance for the rEporting of intervention Development (GUIDED) checklist and the DEVELOPTOOLS Reporting Checklist. PATIENT OR PUBLIC CONTRIBUTION Patients, relatives and health professionals have been involved throughout the research process as part of the research team and advisory board. For this study, the advisory board has particularly contributed to the development process of the DESIRE intervention by actively participating in the four workshops, in the iterations between the workshops and in the preparation of the manuscript.
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Affiliation(s)
- Louise Engelbrecht Buur
- Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark
- Research Centre for Patient Involvement (ResCenPI), Aarhus University, Aarhus, Denmark
- Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Hilary Louise Bekker
- Research Centre for Patient Involvement (ResCenPI), Aarhus University, Aarhus, Denmark
- Department of Public Health, Aarhus University, Aarhus, Denmark
- Leeds Unit of Complex Intervention Development (LUCID), Leeds Institute of Health Science, School of Medicine, University of Leeds, Leeds, UK
| | | | | | | | - Dinah Sherzad Khatir
- Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Jeanette Finderup
- Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark
- Research Centre for Patient Involvement (ResCenPI), Aarhus University, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Buur LE, Bekker HL, Rodkjær LØ, Kvist A, Kristensen JB, Søndergaard H, Kannegaard M, Madsen JK, Khatir DS, Finderup J. Decisional needs in people with kidney failure, their relatives and health professionals about end-of-life care options: A qualitative interview study. J Adv Nurs 2024; 80:3345-3358. [PMID: 38186058 DOI: 10.1111/jan.16037] [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: 09/29/2023] [Revised: 12/01/2023] [Accepted: 12/17/2023] [Indexed: 01/09/2024]
Abstract
AIM To investigate the decisional needs in Denmark of people with kidney failure, relatives, and health professionals when planning end-of-life care. DESIGN A qualitative interview study. METHODS Individual semi-structured interviews were carried out with people with kidney failure, relatives and health professionals from November 2021 to June 2022. Malterud's systematic text condensation was used to analyse transcripts. RESULTS A total of 13 patients, 10 relatives, and 12 health professionals were interviewed. Overall, four concepts were agreed on: (1) Talking about end of life is difficult, (2) Patients and relatives need more knowledge and information, (3) Health professionals need more tools and training, and (4) Experiencing busyness as a barrier to conversations about end of life. CONCLUSION People with kidney failure, relatives, and health professionals shared certain decisional needs while also having some different decisional needs about end-of-life care. To meet these various needs, end-of-life conversations should be systematic and organized according to the patients' needs and wishes. IMPACT Non-systematic end-of-life care decision-making processes limit patients' involvement. Patients and relatives need more knowledge about end-of-life care, and health professionals need more competences and time to discuss decisional needs. A shared decision-making intervention for people with kidney failure when making end-of-life care decisions will be developed. REPORTING METHOD This empirical qualitative research is reported according to the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist. PATIENT OR PUBLIC CONTRIBUTION Patients, relatives, and health professionals have been involved throughout the research process as part of the research team and advisory board. The patients are people with kidney failure and the relatives are relatives of a person with kidney failure. For this study, the advisory board has particularly contributed to the validation of the invitation letter for participation, the interview guides and the preparation of the manuscript.
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Affiliation(s)
- Louise Engelbrecht Buur
- Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark
- Research Centre for Patient Involvement (ResCenPI), Aarhus University, Aarhus, Denmark
- Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Hilary Louise Bekker
- Research Centre for Patient Involvement (ResCenPI), Aarhus University, Aarhus, Denmark
- Department of Public Health, Aarhus University, Aarhus, Denmark
- Leeds Unit of Complex Intervention Development (LUCID), Leeds Institute of Health Science, University of Leeds, Leeds, UK
| | - Lotte Ørneborg Rodkjær
- Research Centre for Patient Involvement (ResCenPI), Aarhus University, Aarhus, Denmark
- Department of Public Health, Aarhus University, Aarhus, Denmark
- Department of Infectious Diseases, Aarhus University Hospital, Aarhus, Denmark
| | - Anne Kvist
- Department of Public Health, Aarhus University, Aarhus, Denmark
| | | | | | | | | | - Dinah Sherzad Khatir
- Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Jeanette Finderup
- Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark
- Research Centre for Patient Involvement (ResCenPI), Aarhus University, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Adenwalla SF, O'Halloran P, Faull C, Murtagh FEM, Graham-Brown MPM. Advance care planning for patients with end-stage kidney disease on dialysis: narrative review of the current evidence, and future considerations. J Nephrol 2024; 37:547-560. [PMID: 38236475 PMCID: PMC11150316 DOI: 10.1007/s40620-023-01841-3] [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: 08/15/2023] [Accepted: 11/18/2023] [Indexed: 01/19/2024]
Abstract
Patients with end-stage kidney disease (ESKD) have a high symptom-burden and high rates of morbidity and mortality. Despite this, evidence has shown that this patient group does not have timely discussions to plan for deterioration and death, and at the end of life there are unmet palliative care needs. Advance care planning is a process that can help patients share their personal values and preferences for their future care and prepare for declining health. Earlier, more integrated and holistic advance care planning has the potential to improve access to care services, communication, and preparedness for future decision-making and changing circumstances. However, there are many barriers to successful implementation of advance care planning in this population. In this narrative review we discuss the current evidence for advance care planning in patients on dialysis, the data around the barriers to advance care planning implementation, and interventions that have been trialled. The review explores whether the concepts and approaches to advance care planning in this population need to be updated to encompass current and future care. It suggests that a shift from a problem-orientated approach to a goal-orientated approach may lead to better engagement, with more patient-centred and satisfying outcomes.
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Affiliation(s)
- S F Adenwalla
- Department of Cardiovascular Sciences, University of Leicester, Leicester, LE1 9HN, UK.
- NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK.
- John Walls Renal Unit, University Hospitals Leicester NHS Trust, Leicester, UK.
| | - P O'Halloran
- School of Nursing and Midwifery, Medical Biology Centre, Queen's University Belfast, Belfast, UK
| | - C Faull
- Leicestershire and Rutland Organisation for the Relief of Suffering (LOROS) Hospice, Leicester, UK
| | - F E M Murtagh
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - M P M Graham-Brown
- Department of Cardiovascular Sciences, University of Leicester, Leicester, LE1 9HN, UK
- NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK
- John Walls Renal Unit, University Hospitals Leicester NHS Trust, Leicester, UK
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de Barbieri I, Strini V, Noble H, Carswell C, Rocchi MBL, Sisti D. Facilitators and Barriers to Receiving Palliative Care in People with Kidney Disease: Predictive Factors from an International Nursing Perspective. NURSING REPORTS 2024; 14:220-229. [PMID: 38391063 PMCID: PMC10885022 DOI: 10.3390/nursrep14010018] [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: 11/16/2023] [Revised: 12/26/2023] [Accepted: 01/18/2024] [Indexed: 02/24/2024] Open
Abstract
BACKGROUND Palliative care (PC) focuses on relieving pain and difficult symptoms rather than treating disease or delaying its progress. Palliative care views death as a natural process and allows patients to live the last phase of their existence in the best possible way, encouraging them to express their opinions and wishes for a good death. Interventions are advocated to control symptoms and distress and promote wellbeing and social functioning. A multidisciplinary approach to support patients receiving palliative care is encouraged. OBJECTIVE The aims of this study were to investigate the facilitators and barriers to PC in people with kidney disease from a nursing perspective and to explore predictive factors associated with nurse-perceived facilitators and barriers to PC in people with kidney disease. DESIGN This study is a survey that adopted a questionnaire created in 2021 with Delphi methology, which included 73 statements divided into 37 facilitators and 36 barriers to PC in patients with kidney disease, to be scored using a Likert scale. PARTICIPANTS AND MEASUREMENTS Participants were obtained through the membership database of the European Dialysis and Transplant Nurses Association/European Renal Care Association (EDTNA/ERCA) of 2020. Inclusion criteria included being registered as a nurse, an EDTNA/ERCA member and understanding of the English language. The questionnaire was sent via email. RESULTS Three profiles of respondents were found: the first group was characterized by the highest agreement percentages of facilitators and with an average value of 53.7% in barriers; the second was characterized by a lower endorsement of facilitators and similar agreement to the first group for barriers; the third group had a high probability (>80%) of items endorsing both barriers and facilitators. Predictive variables were significantly associated with "Years in nephrology" and "macro geographic area". CONCLUSIONS This study demonstrates variation in PC practice across Europe. Some professionals identified fewer barriers to PC and appeared more confident when dealing with difficult situations in a patient's care pathway, while others identified more barriers as obstacles to the implementation of adequate treatment. The number of years of nephrology experience and the geographical area of origin predicted how nurses would respond. This study was not registered.
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Affiliation(s)
- Ilaria de Barbieri
- Woman's and Child's Health Department, Padua University Hospital, 45128 Padova, Italy
| | - Veronica Strini
- Clinical Research Unit, Padua University Hospital, 45128 Padova, Italy
| | - Helen Noble
- School of Nursing and Midwifery, Queens University Belfast, Belfast BT9 7BL, UK
| | - Claire Carswell
- School of Nursing and Midwifery, Queens University Belfast, Belfast BT9 7BL, UK
| | - Marco Bruno Luigi Rocchi
- Department of Biomolecular Sciences, Service of Biostatistics, University of Urbino, 61029 Urbino, Italy
| | - Davide Sisti
- Department of Biomolecular Sciences, Service of Biostatistics, University of Urbino, 61029 Urbino, Italy
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Ramakrishnan C, Widjaja N, Malhotra C, Finkelstein E, Khan BA, Ozdemir S. Unravelling complex choices: multi-stakeholder perceptions on dialysis withdrawal and end-of-life care in kidney disease. BMC Nephrol 2024; 25:6. [PMID: 38172719 PMCID: PMC10765633 DOI: 10.1186/s12882-023-03434-5] [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: 06/21/2023] [Accepted: 12/10/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND For patients on dialysis with poor quality of life and prognosis, dialysis withdrawal and subsequent transition to palliative care is recommended. This study aims to understand multi-stakeholder perspectives regarding dialysis withdrawal and identify their information needs and support for decision-making regarding withdrawing from dialysis and end-of-life care. METHODS Participants were recruited through purposive sampling from eight dialysis centers and two public hospitals in Singapore. Semi-structured in-depth interviews were conducted with 10 patients on dialysis, 8 family caregivers, and 16 renal healthcare providers. They were held in-person at dialysis clinics with patients and caregivers, and virtually via video-conferencing with healthcare providers. Interviews were audio-recorded, transcribed, and thematically analyzed. The Ottawa Decision Support Framework's decisional-needs manual was used as a guide for data collection and analysis, with two independent team members coding the data. RESULTS Four themes reflecting perceptions and support for decision-making were identified: a) poor knowledge and fatalistic perceptions; b) inadequate resources and support for decision-making; c) complexity of decision-making, unclear timing, and unpreparedness; and d) internal emotions of decisional conflict and regret. Participants displayed limited awareness of dialysis withdrawal and palliative care, often perceiving dialysis withdrawal as medical abandonment. Patient preferences regarding decision-making ranged from autonomous control to physician or family-delegated choices. Cultural factors contributed to hesitancy and reluctance to discuss end-of-life matters, resulting in a lack of conversations between patients and providers, as well as between patients and their caregivers. CONCLUSIONS Decision-making for dialysis withdrawal is complicated, exacerbated by a lack of awareness and conversations on end-of-life care among patients, caregivers, and providers. These findings emphasize the need for a culturally-sensitive tool that informs and prepares patients and their caregivers to navigate decisions about dialysis withdrawal and the transition to palliative care. Such a tool could bridge information gaps and stimulate meaningful conversations, fostering informed and culturally aligned decisions during this critical juncture of care.
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Affiliation(s)
- Chandrika Ramakrishnan
- Duke-NUS Medical School, Lien Centre for Palliative Care, Programme in Health Services and Systems Research, Singapore, Singapore
- Duke NUS Medical School, Signature Programme in Health Services and Research, Singapore, Singapore
| | - Nathan Widjaja
- Duke-NUS Medical School, Lien Centre for Palliative Care, Programme in Health Services and Systems Research, Singapore, Singapore
- Nanyang Technological University, Singapore, Singapore
| | - Chetna Malhotra
- Duke-NUS Medical School, Lien Centre for Palliative Care, Programme in Health Services and Systems Research, Singapore, Singapore
- Duke NUS Medical School, Signature Programme in Health Services and Research, Singapore, Singapore
| | - Eric Finkelstein
- Duke-NUS Medical School, Lien Centre for Palliative Care, Programme in Health Services and Systems Research, Singapore, Singapore
- Duke NUS Medical School, Signature Programme in Health Services and Research, Singapore, Singapore
- Department of Population Health Sciences, Duke University, Durham, NC, USA
| | - Behram Ali Khan
- Division of Nephrology, National University Health System, Singapore, Singapore
- National Kidney Foundation, Singapore, Singapore
| | - Semra Ozdemir
- Duke-NUS Medical School, Lien Centre for Palliative Care, Programme in Health Services and Systems Research, Singapore, Singapore.
- Duke NUS Medical School, Signature Programme in Health Services and Research, Singapore, Singapore.
- Department of Population Health Sciences, Duke University, Durham, NC, USA.
- Duke Clinical Research Institute, Duke University, Durham, NC, USA.
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Horning MA, Bowen ME. Characterizing end-of-life communication in families. Palliat Care Soc Pract 2023; 17:26323524231193033. [PMID: 37674618 PMCID: PMC10478557 DOI: 10.1177/26323524231193033] [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: 04/22/2023] [Accepted: 07/21/2023] [Indexed: 09/08/2023] Open
Abstract
Background The chronic disease course can be uncertain, contributing to delayed end-of-life discussion within families resulting in missed opportunity to articulate wishes, increased decisional uncertainty, and delayed hospice care. Consistent with the Family Communication Patterns Theory (FCPT), family communication patterns may affect the quality and timing of end-of-life discussion, hospice utilization, and the experience of 'a good death.' Objective To assess how families' conversation and conformity orientation (spontaneity of conversation and hierarchical rigidity) form four family communication patterns (consensual, pluralistic, protective, and laissez-faire) and may be associated with the number and timing of end-of-life discussions. Design A cross-sectional study. Methods Family members of loved ones who died from chronic illnesses while in hospice (n = 56) completed online surveys including a modified Revised Family Communication Pattern instrument (RFCP) and the Chronic Illness Rating Scale (CIRS). Additional survey questions assessed the number and timing of end-of-life discussions and timing of hospice enrollment. IBM SPSS version 26 was used for descriptive analysis. Results Most families (42.9%) were pluralistic, reporting communication styles with high conversation and low conformity orientation; (39.29%) were protective, reporting low conversation and high conformity orientation. Pluralistic families had more end-of-life conversations than did protective families. Conclusion Study findings suggest that there may be a relationship between family communication pattern type and inclination toward end-of-life discussion. This first step supports future research regarding whether the FCPT can be used to predict which families may be at increased risk for ineffective or delayed end-of-life discussion. Additional variables to consider include the timing of hospice enrollment and the quality of the dying experience. Clinicians may ultimately use findings to facilitate earlier identification of and intervention for families who are at risk for poor end-of-life communication and outcomes.
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Affiliation(s)
- Melanie A. Horning
- Department of Nursing, Towson University, 8000 York Road, Towson, MD 21252, USA
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10
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Ducharlet K, Weil J, Gock H, Philip J. Kidney Clinicians' Perceptions of Challenges and Aspirations to Improve End-Of-Life Care Provision. Kidney Int Rep 2023; 8:1627-1637. [PMID: 37547531 PMCID: PMC10403660 DOI: 10.1016/j.ekir.2023.04.031] [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] [Received: 11/16/2022] [Revised: 02/26/2023] [Accepted: 04/10/2023] [Indexed: 08/08/2023] Open
Abstract
Introduction End-of-life care is an essential part of integrated kidney care. However, renal clinicians' experiences of care provision and perceptions of end-of-life care needs are limited. This study explored renal clinicians' experiences of providing end-of-life care and developed recommendations to improve experiences. Methods An exploratory qualitative study using semistructured focus groups and 1 interview was undertaken at 5 kidney services in Victoria, Australia. The transcripts were analyzed thematically. Results Between February and December 2017, 54 renal clinicians (21 doctors and 33 nurses) participated in the study. Clinicians reported multiple challenges of end-of-life care experiences resulting in compromised treatment planning and decision making and highlighted priorities to guide better care experiences. Challenges of providing end-of-life care were underpinned by mismatches in illness and treatment expectations, limited engagement in advance care planning, medical complexity, and differences between clinicians and patients in what constituted quality of life. These challenges were associated with compromised end-of-life care planning, which resulted in care experiences that were rushed with a prolonged treatment focus, risking limited preparation for death and moral distress. Clinicians aspired for positive end-of-life care experiences, including patient control and consensus in decision making, and a coordinated and collaborative approach across healthcare providers. Conclusions Renal clinicians highlighted multiple factors and circumstances which resulted in experiences of compromised end-of-life care for patients with kidney disease. To improve care experiences, clinician-directed priorities included more training and support to facilitate systematic and earlier discussions about illness expectations and end-of-life care planning and greater communication and collaboration across healthcare providers is required.
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Affiliation(s)
- Kathryn Ducharlet
- Department of Palliative Medicine, St Vincent’s Hospital Melbourne, Melbourne, Victoria, Australia
- Department of Nephrology, St Vincent’s Hospital Melbourne, Melbourne, Victoria, Australia
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
- Eastern Health Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Jennifer Weil
- Department of Palliative Medicine, St Vincent’s Hospital Melbourne, Melbourne, Victoria, Australia
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Hilton Gock
- Department of Nephrology, St Vincent’s Hospital Melbourne, Melbourne, Victoria, Australia
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Jennifer Philip
- Department of Palliative Medicine, St Vincent’s Hospital Melbourne, Melbourne, Victoria, Australia
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
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11
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Kowaloff R. Even at the end of life, patients of color are denied equity. J Natl Med Assoc 2023; 115:319-320. [PMID: 37032268 DOI: 10.1016/j.jnma.2023.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 01/31/2023] [Accepted: 03/14/2023] [Indexed: 04/11/2023]
Affiliation(s)
- Rebecca Kowaloff
- Umass Medical School, Department of Palliative Medicine, 55 Lake Ave N., Worcester, MA 01606.
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12
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Alshehri HH, Wolf A, Öhlén J, Olausson S. Healthcare Professionals' Perspective on Palliative Care in Intensive Care Settings: An Interpretive Descriptive Study. Glob Qual Nurs Res 2022; 9:23333936221138077. [PMID: 36507302 PMCID: PMC9729985 DOI: 10.1177/23333936221138077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 09/24/2022] [Accepted: 10/04/2022] [Indexed: 12/12/2022] Open
Abstract
There is a growing need to integrate palliative care into intensive care units and to develop appropriate knowledge translation strategies. However, multiple challenges persist in attempts to achieve this objective. In this study, we aimed to explore intensive care professionals' perspectives on providing palliative and end-of-life care within an intensive care context. We used an interpretive description approach and interviewed 36 intensive care professionals at four hospitals in Saudi Arabia. Our findings reflect a discourse about end-of-life care driven by a do-not-resuscitate classification and challenges associated with family involvement in care goals. We provide key insights of importance for the development of strategies for the integration and knowledge translation of palliative care into intensive care contexts.
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Affiliation(s)
- Hanan Hamdan Alshehri
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden
- Hanan Hamdan Alshehri, University of Gothenburg Sahlgrenska Academy, Box 457 405 30 Göteborg, Goteborg 405 30, Sweden. Emails: ;
| | - Axel Wolf
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden
- University of Gothenburg and Region Västra Götaland, Sahlgrenska University Hospital/Östra, Sweden
| | - Joakim Öhlén
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden
- University of Gothenburg and Palliative Centre, Sahlgrenska University Hospital Region Västra Götaland, Sweden
| | - Sepideh Olausson
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden
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13
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Johnson E, Jack B. Grey area nursing: high-dependency nurses’ experiences of caring for patients approaching the transition from curative to palliative care. Int J Palliat Nurs 2022; 28:515-521. [DOI: 10.12968/ijpn.2022.28.11.515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background: Nurses in high-dependency units frequently facilitate the withdrawal of life-sustaining treatments and provide end-of-life care. Providing this care has been shown to cause distress, burnout and cumulative grief. There remains a lack of understanding of high dependency nurses’ experiences of caring for patients approaching withdrawal of life-sustaining treatments. Aim: To explore experiences of high dependency nurses caring for patients approaching withdrawal of life-sustaining treatment and highlight any support or needs they may have. Methods: Interviews were conducted and analysed using qualitative thematic analysis. Findings: Nurses experienced conflict in decision making, which was reported to prolong patient distress and cause nurses moral anguish. Nurses need time to talk and further education to support them to provide withdrawal of life-sustaining treatment. Conclusion: High-dependency nurses need time to talk following caring for this patient group and more extensive education to support them to provide quality end-of-life care.
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Affiliation(s)
- Emily Johnson
- Palliative Care Nurse, Liverpool Foundation Trust, UK
| | - Barbara Jack
- Professor of Palliative and End-of-Life Care; Academic Programme Lead (MSc/PG Cert Integrated), Queenscourt Hospice, Edge Hill University, UK
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14
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Qureshi SP, Jones D, Dewar A. Physicians' Conceptions of the Dying Patient: Scoping Review and Qualitative Content Analysis of the United Kingdom Medical Literature. QUALITATIVE HEALTH RESEARCH 2022; 32:1881-1896. [PMID: 35981561 PMCID: PMC9511242 DOI: 10.1177/10497323221119939] [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] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Most people in high income countries experience dying while receiving healthcare, yet dying has no clear beginning, and contexts influence how dying is conceptualised. This study investigates how UK physicians conceptualise the dying patient. We employed Scoping Study Methodology to obtain medical literature from 2006-2021, and Qualitative Content Analysis to analyse stated and implied meanings of language used, informed by social-materialism. Our findings indicate physicians do not conceive a dichotomous distinction between dying and not dying, but construct conceptions of the dying patient in subjective ways linked to their practice. We argue that the focus of future research should be on exploring practice-based challenges in the workplace to understanding patient dying. Furthermore, pre-Covid-19 literature related dying to chronic illness, but analysis of literature published since the pandemic generated conceptions of dying from acute illness. Researchers should note the ongoing effects of Covid-19 on societal and medical awareness of dying.
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Affiliation(s)
- Shaun Peter Qureshi
- Edinburgh Medical School, The University of Edinburgh Edinburgh Medical School, Edinburgh, UK
| | - Derek Jones
- Edinburgh Medical School, The University of Edinburgh Edinburgh Medical School, Edinburgh, UK
| | - Avril Dewar
- Edinburgh Medical School, The University of Edinburgh Edinburgh Medical School, Edinburgh, UK
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15
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Rozi NRB, Bin Wan Ali WASR, Bin Draman CR, Pasi HB, Rathor MY. Knowledge and Perceptions on End-of-life Care among End-stage Renal Disease Patients on Hemodialysis. SAUDI JOURNAL OF KIDNEY DISEASES AND TRANSPLANTATION 2022; 33:664-673. [PMID: 37955458 DOI: 10.4103/1319-2442.389426] [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: 11/14/2023] Open
Abstract
The role of end-of-life care is fundamental for end-stage renal disease (ESRD) patients, who are known to have a high morbidity and mortality rate despite being on dialysis. This requires effective communication and shared decision-making. Thus, exploring patients' knowledge and perceptions is essential to improve the gaps in delivering end-of-life care. This study aimed to describe the knowledge and perceptions of end-of-life care among ESRD patients on hemodialysis (HD). This was a cross-sectional study involving 14 outpatient HD centers in Kuantan, Malaysia. Patients were recruited from March to June 2019. A validated questionnaire was delivered via interview-based surveys by the researcher or trained interviewers. The majority of the respondents had poor knowledge of the disease and end-of-life care. However, more than 70% of the respondents felt that it was important for them to be actively involved in medical decision-making, as well as being prepared and planning for death. End-of-life needs, which included management of symptoms and psychological, social, and spiritual support, were important to most respondents. Additionally, patients with higher educational backgrounds were observed to have higher scores for both knowledge and perceptions (P <0.05). The study found poor knowledge but acceptable perceptions among patients. This highlights the gaps in the current local approach in clinical practice to end-of-life care in ESRD.
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Affiliation(s)
- Nur Raziana Binti Rozi
- Department of Internal Medicine, Kulliyyah of Medicine, International Islamic University, Kuantan, Pahang, Malaysia
| | | | - Che Rosle Bin Draman
- Department of Internal Medicine, Kulliyyah of Medicine, International Islamic University, Kuantan, Pahang, Malaysia
| | - Hafizah Binti Pasi
- Department of Community Health, Kulliyyah of Medicine, International Islamic University, Kuantan, Pahang, Malaysia
| | - Mohammad Yousuf Rathor
- Department of Internal Medicine, Kulliyyah of Medicine, International Islamic University, Kuantan, Pahang, Malaysia
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16
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Vilpert S, Borasio GD, Maurer J. Knowledge Gaps in End-of-Life Care and Planning Options Among Older Adults in Switzerland. Int J Public Health 2022; 67:1604676. [PMID: 36090825 PMCID: PMC9453860 DOI: 10.3389/ijph.2022.1604676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 06/24/2022] [Indexed: 11/30/2022] Open
Abstract
Objectives: Good knowledge about end-of-life (EOL) care options helps in discussing and planning important aspects of the end of life in advance and contributes to improved well-being among dying patients and their families. Methods: Our study explores knowledge levels of EOL care and planning options and its sociodemographic and regional patterning using nationally representative data from respondents aged 55+ of wave 6 of the Survey of Health, Ageing and Retirement in Europe in Switzerland (n = 2,199). Results: Respondents answered correctly on average to just under four out of eight questions regarding EOL care options. Women, individuals with higher education levels, and those living with a partner showed a higher EOL knowledge score, whereas the score is lower among older adults (75+) and individuals living in French- and Italian-speaking Switzerland. Conclusion: In view of the significant EOL knowledge gaps among older adults in Switzerland, further education efforts on EOL care options are needed, with particular attention to the population groups most affected.
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Affiliation(s)
- Sarah Vilpert
- Faculty of Business and Economics (HEC), University of Lausanne, Lausanne, Switzerland
- Swiss Centre of Expertise in the Social Sciences, Lausanne, Switzerland
- *Correspondence: Sarah Vilpert,
| | - Gian Domenico Borasio
- Palliative and Supportive Care Service, Lausanne University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Jürgen Maurer
- Faculty of Business and Economics (HEC), University of Lausanne, Lausanne, Switzerland
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17
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Douglass-Molloy H, Law MM, Le B, Katz N. Spiritual distress in dialysis: A case report. PROGRESS IN PALLIATIVE CARE 2022. [DOI: 10.1080/09699260.2022.2090052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
| | | | - Brian Le
- Royal Melbourne Hospital, Victoria, Australia
- Peter MacCallum Cancer Centre, Victoria, Australia
| | - Naomi Katz
- Peter MacCallum Cancer Centre, Victoria, Australia
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18
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Maniam R, Tan MP, Chong MC. End of life care preference among hemodialysis population: Revisit Q methodology. PATIENT EDUCATION AND COUNSELING 2022; 105:1495-1502. [PMID: 34625322 DOI: 10.1016/j.pec.2021.09.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 09/09/2021] [Accepted: 09/19/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE End-of-life care is often overlooked in the dialysis unit despite high mortality rates. This study aimed to understand the diverse subjectivity of opinions on end-of-life care preferences, feelings, needs, value and goals in life among a haemodialysis population. METHODS The Q methodology was used where 37 opinion statements were ranked in order of importance in a unimodal shaped grid. Results were explored using the Centroids factor extraction and Varimax rotation. RESULTS Four-three persons living with haemodialysis, mean age± SD= 56.58 ± 10.22 years, participated in the study. Five-factors were identified: living in the present, family preference, self preservation, power vs. control and autonomy in decision making, loaded by eleven, four, four, three and three participants with 16 individuals not loading significantly and two were confounded. Preferences for remaining positive in the face of illness through a healthy lifestyle and preserving relationships and autonomy were demonstrated. CONCLUSIONS End-of-life discussions are potentially inhibited by preferences to live for the present which should be explored in future studies. PRACTICE IMPLICATION Statement sets may be used to help facilitate end-of-life discussions through identification of opinion groups. Establishing preferences may guide identification of those willing to initiate discussions.
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Affiliation(s)
- Radha Maniam
- Department of Nursing Science, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia.
| | - Maw Pin Tan
- Department of Medicine, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur Malaysia.
| | - Mei Chan Chong
- Department of Nursing Science, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia.
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19
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Russell J, Quaack K. A Multiple Goals Approach to Exploring Social Worker Conversational Plans for Advance Care Treatment with Terminally Ill Patients. JOURNAL OF SOCIAL WORK IN END-OF-LIFE & PALLIATIVE CARE 2021; 17:278-295. [PMID: 33866957 DOI: 10.1080/15524256.2021.1910107] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Social workers play an integral role in end-of-life planning and patient outcomes, and yet how social workers approach such conversations with patients is not well understood. The current study employed a cross-sectional design to examine social worker planned communication about end-of-life care using a multiple goals framework. Recruited from online listservs, a content analysis was conducted with social worker curated plans (n = 20) for end-of-life conversations. Plans were coded for topics and content alignment with instrumental, identity, and relational goal types. Topics found were related to eliciting patient goals and the utilization of written resources. A substantial percentage of social workers also noted the inclusion of other parties in the conversation. Findings suggested that content was predominately instrumental (i.e. task-oriented) with an overwhelming majority adhering to multiple conversational goals. Plan content affords insight to occupational orientation and prioritization during conversations with patients. Further, identifying how the majority of planned responses integrate multiple goals simultaneously gives credence to existing research regarding enhanced conversational effectiveness when social workers are present on the palliative care team.
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Affiliation(s)
- Jessica Russell
- Communication Studies, California State University, Long Beach, California, USA
| | - Karly Quaack
- The University of Texas at Austin College of Liberal Arts, Austin, Texas, USA
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20
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The use of altered rapid response calling criteria in a tertiary referral facility. Aust Crit Care 2021; 34:204-208. [DOI: 10.1016/j.aucc.2020.07.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Revised: 07/15/2020] [Accepted: 07/30/2020] [Indexed: 11/21/2022] Open
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21
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Martin DE, Muller E. In Defense of Patient Autonomy in Kidney Failure Care When Treatment Choices Are Limited. Semin Nephrol 2021; 41:242-252. [PMID: 34330364 DOI: 10.1016/j.semnephrol.2021.05.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Respect for patient autonomy is a primary ethical obligation of health care providers. In kidney health care, clinical practice recommendations commonly include strategies to promote shared decision making with patients and their families about treatment options to promote patient autonomy and improve patient outcomes. However, for many people with kidney failure, treatment options may be unavailable or inaccessible. In these circumstances some clinicians may act paternalistically and withhold information from patients because of a fear of causing harm or because clinicians believe that patient autonomy is not a relevant consideration. In this article, we reflect on the concept of autonomy in the context of clinical decision making in kidney failure care, with particular attention to resource-constrained settings and the disclosure of information to patients for whom treatment may be inaccessible. We examine and address key concerns that patient autonomy may be impossible, irrelevant, or harmful in the context of limited treatment choices, and discuss factors that may influence paternalistic practices in such settings. We conclude that respect for autonomy is intrinsically and instrumentally valuable, and argue that in neglecting patient autonomy in resource-constrained settings, clinicians may exacerbate and entrench the structural inequalities and health inequities they are committed to addressing.
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Affiliation(s)
| | - Elmi Muller
- Department of Surgery, University of Cape Town, Cape Town, South Africa
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22
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de Barbieri I, Strini V, Noble H, Amatori S, Sisti D. Nurse-perceived facilitators and barriers to palliative care in patients with kidney disease: A European Delphi survey. J Ren Care 2021; 48:49-59. [PMID: 33763991 PMCID: PMC9135123 DOI: 10.1111/jorc.12371] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 02/22/2021] [Accepted: 03/08/2021] [Indexed: 12/05/2022]
Abstract
Background The palliative care phenomenon is increasingly invested in all medicine and nursing fields, as care for people with kidney disease who do not wish to embark on dialysis: it encompasses a palliative approach to shared decision‐making. To deliver patient‐centred optimal care, nephrology healthcare staff should be knowledgeable about palliative care and the appropriate conservative management approach. Objective This paper aimed to explore, using a Delphi survey, the barriers and facilitators to palliative care in patients with kidney disease. Design An e‐Delphi technique with three questionnaire rounds was performed; statements were generated using Likert scales. Participants and Measurements A list of 80 statements related to palliative care in patients with kidney disease was divided into facilitators and barriers. Questionnaires were administered to 13 nephrology nurse experts in some European countries. Results Seven items were removed from the list of 80 statements after the first round of the Delphi study; eight items achieved a significant change of the mean between round two and three, whereas internal stability emerged in all the remaining items. Conclusions Specific training and education in palliative care emerged as a facilitator, as well as the role of spiritual and beliefs and the role of family and caregiver. The main barriers were represented by the differences in cultures, beliefs, and practices and by the lack of experience in the role of the staff in palliative care. These statements provide a platform for future research to improve palliative care practice in patients with kidney disease.
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Affiliation(s)
- Ilaria de Barbieri
- Department of Health Professions, University Hospital of Padova, Padova, Italy
| | - Veronica Strini
- Projects and Clinical Research Unit, University Hospital of Padova, Padova, Italy
| | - Helen Noble
- School of Nursing and Midwifery, Queens's University Belfast, Belfast, UK
| | - Stefano Amatori
- Department of Biomolecular Sciences, Service of Biostatistics, University of Urbino Carlo Bo, Urbino, Italy
| | - Davide Sisti
- Department of Biomolecular Sciences, Service of Biostatistics, University of Urbino Carlo Bo, Urbino, Italy
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23
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Angheluta AA, Gonella S, Sgubin C, Dimonte V, Bin A, Palese A. When and how clinical nurses adjust nursing care at the end-of-life among patients with cancer: Findings from multiple focus groups. Eur J Oncol Nurs 2020; 49:101856. [PMID: 33120222 DOI: 10.1016/j.ejon.2020.101856] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Revised: 10/04/2020] [Accepted: 10/15/2020] [Indexed: 11/16/2022]
Abstract
PURPOSE Defining patients as 'terminally-ill' may be difficult. Therefore, determining when to shift the goal of care from curative to comfort care may be extremely challenging. The aim of this study was to merge when and how Registered Nurses (RNs) and Nurses' Assistants (NAs) adjust end-of-life care to pursue patient comfort at the end of their lives. METHODS A descriptive qualitative study based on multiple focus groups was performed in 2017 according to the COnsolidated criteria for REporting Qualitative research guidelines. In all, 25 RNs and 16 NAs across seven north-east Italian facilities that provide end-of-life care, voluntarily participated in the study. Each focus group was conducted following the same interview guide with open-ended questions, and was audiotaped. A thematic analysis was applied to interview transcripts. RESULTS The process of nursing care plan adjustment is based upon two main themes, around 'when' and 'how' to adjust it. Regarding when, 'Detecting the turning point', and 'Being ready to change continuously until the end' emerged as the main sub-themes. Regarding how, 'Weighing harms and benefits of nursing care interventions'; 'Advocating for patients' wishes', 'Sharing the adjustments inside the team at different levels', 'Involving family in the adjustments of nursing care'; and 'Allowing care to move away from evidence-based practice' were the sub-themes emerged. CONCLUSIONS Shedding light on the implicit decisional processes that inform care adjustments and the implementation of related strategies is essential to improve the quality of end-of-life care given that an early detection of the terminal phase has been reported to result in changes of care improving outcomes.
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Affiliation(s)
| | | | | | | | - Alessandra Bin
- Azienda Sanitaria Universitaria Integrata di Udine, Oncological Department, Udine, Italy
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24
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Scholz B, Goncharov L, Emmerich N, Lu VN, Chapman M, Clark SJ, Wilson T, Slade D, Mitchell I. Clinicians' accounts of communication with patients in end-of-life care contexts: A systematic review. PATIENT EDUCATION AND COUNSELING 2020; 103:1913-1921. [PMID: 32650998 DOI: 10.1016/j.pec.2020.06.033] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 06/02/2020] [Accepted: 06/29/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE Communication between patients and end-of-life care providers requires sensitivity given the context and complexity involved. This systematic review uses a narrative approach to synthesise clinicians' understandings of communication in end-of-life care. METHODS A systematic, narrative synthesis approach was adopted given the heterogeneity across the 83 included studies. The review was registered prospectively on PROSPERO (ID: CRD42019125155). Medline was searched for all articles catalogued with the MeSH terms "palliative care," "terminal care" or "end-of-life care," and "communication". Articles were assessed for quality using a modified JQI-QARI tool. RESULTS The findings highlight the centrality and complexity of communication in end-of-life care. The challenges identified by clinicians in relation to such communication include the development of skills necessary, complexity of interpersonal interactions, and ways in which organisational factors impact upon communication. Clinicians are also aware of the need to develop strategies for interdisciplinary teams to improve communication. CONCLUSION Training needs for effective communication in end-of-life contexts are not currently being met. PRACTICE IMPLICATIONS Clinicians need more training to address the lack of skills to overcome interactional difficulties. Attention is also needed to address issues in the organisational contexts in which such communication occurs.
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Affiliation(s)
- Brett Scholz
- Medical School, The Australian National University, Canberra, Australia.
| | - Liza Goncharov
- School of Literature, Languages and Linguistics, The Australian National University, Canberra, Australia
| | - Nathan Emmerich
- Medical School, The Australian National University, Canberra, Australia
| | - Vinh N Lu
- College of Business and Economics, The Australian National University, Canberra, Australia
| | - Michael Chapman
- Medical School, The Australian National University, Canberra, Australia; Canberra Health Service, ACT Health, Canberra, Australia
| | - Shannon J Clark
- School of Literature, Languages and Linguistics, The Australian National University, Canberra, Australia
| | - Tracey Wilson
- Medical Intensive Care Unit, University of Maryland, Baltimore, USA
| | - Diana Slade
- School of Literature, Languages and Linguistics, The Australian National University, Canberra, Australia
| | - Imogen Mitchell
- Medical School, The Australian National University, Canberra, Australia; Canberra Health Service, ACT Health, Canberra, Australia
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Ducharlet K, Philip J, Kiburg K, Gock H. Renal supportive care, palliative care and end-of-life care: Perceptions of similarities, differences and challenges across Australia and New Zealand. Nephrology (Carlton) 2020; 26:15-22. [PMID: 32989844 DOI: 10.1111/nep.13787] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Revised: 07/15/2020] [Accepted: 09/16/2020] [Indexed: 12/21/2022]
Abstract
Renal supportive care (RSC) is an approach integrating nephrology and palliative care to improve quality of life for people with chronic kidney disease (CKD). RSC practice varies across services; therefore, understanding clinicians' perspectives is important to the evolution and definition of RSC. AIM To understand renal clinicians' views and experiences of RSC, palliative care and end-of-life care. METHOD A cross-sectional online survey was undertaken across Australia and New Zealand between February and May 2018. Participants were asked about end-of-life care, RSC, palliative care and an ideal model of RSC. RESULTS Estimated response rate 13% included 382 clinicians; doctors (32%), nurses (68%); of whom 84% access specialist palliative care and 59% RSC. A lack of agreed treatment goals (86%) and late or rushed treatment decision making (85%) was associated with challenging end-of-life experiences. Variable concepts of RSC were described, with RSC being considered the same as: usual care for all CKD patients (40%), conservative (30%) or palliative care (22%). The term RSC was generally distinct from (77%) and more acceptable than palliative care (80%) with preferential RSC referral for symptoms (86% vs 69%, P < .01) and complex treatment decision making (82% vs 58%, P < .01). Aspirations for RSC included improving symptoms and quality of life (89%), with an ideal model comprising: symptom management (98%), improved nephrology and community service integration (96%) and clinician education (94%). CONCLUSION This study revealed challenges for renal clinicians in providing end-of-life care and variation of views and experiences of RSC. It represents opportunities to develop RSC aligned with clinician priorities to improve patient care.
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Affiliation(s)
- Kathryn Ducharlet
- Department of Medicine, Melbourne University, Melbourne, Victoria, Australia.,Department of Nephrology, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia.,Department of Palliative Medicine, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Jennifer Philip
- Department of Medicine, Melbourne University, Melbourne, Victoria, Australia.,Department of Palliative Medicine, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Katerina Kiburg
- Department of Medicine, Melbourne University, Melbourne, Victoria, Australia
| | - Hilton Gock
- Department of Medicine, Melbourne University, Melbourne, Victoria, Australia.,Department of Nephrology, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
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Sarfo-Walters C, Boateng EA. Perceptions of patients with end-stage kidney disease (ESKD) and their informal caregivers on palliative care as a treatment option: a qualitative study. BMC Palliat Care 2020; 19:133. [PMID: 32819349 PMCID: PMC7441556 DOI: 10.1186/s12904-020-00640-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 08/16/2020] [Indexed: 12/03/2022] Open
Abstract
Background Palliative care is increasingly becoming an accepted treatment choice for many individuals diagnosed with end-stage kidney disease (ESKD). Yet, its utilisation is non-existent in many lower- and middle-income countries (LMICs). This study explored the perceptions of individuals with ESKD and their informal caregivers on palliative care as a treatment option for the disease in Ghana. Methods This was a phenomenological study, with an in-depth analysis of data collected from nine individuals with ESKD and six informal caregivers through individual, face-to-face semi-structured interviews. The study was conducted in two renal centres within the Kumasi metropolis, Ghana among individuals with ESKD seeking care from both renal centres and their informal caregivers. Results Three main themes were derived from this study – motivation for initiating haemodialysis, facing realities of haemodialysis, and considering palliative care. Participants felt that haemodialysis (HD) was not meeting their health expectations and demonstrated a general willingness to utilise palliative care if it would reduce suffering. Conclusions This study has shown that individuals with ESKD or their informal caregivers would consider palliative care services, if available. It paves the way for discussions about palliative care for ESKD to begin across renal centres within Ghana and other similar settings. Exploring perspectives of clinicians in such settings could inform strategies on how to implement palliative care for ESKD management in such settings.
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Affiliation(s)
| | - Edward Appiah Boateng
- Department of Nursing, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana.
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Samuriwo R, Lovell-Smith C, Anstey S, Job C, Hopkinson J. Nurses' decision-making about cancer patients' end-of-life skin care in Wales: an exploratory mixed-method vignette study protocol. BMJ Open 2020; 10:e034938. [PMID: 32624470 PMCID: PMC7337620 DOI: 10.1136/bmjopen-2019-034938] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
INTRODUCTION Patients with cancer are at high risk of developing pressure ulcers at the end of life as a result of their underlying condition or cancer treatment. There are many guidelines which set out best practice with regard to end-of-life skin care. However, the complexity of palliative cancer care often means that it is challenging for nurses to make the appropriate person-centred decisions about end-of-life skin care. This study seeks to explore the perceived importance that nurses place on different factors in their end-of-life skin care for patients with cancer. The utility, face validity and content validity of a prototype decision-making tool for end-of-life skin care will also be evaluated. METHODS AND ANALYSIS A mixed-method design will be used to gather data from primary and secondary care nurses working in different hospitals and local authority areas across Wales. Clinical vignettes will be used to gather qualitative and quantitative data from nurses in individual interviews. Qualitative data will be subject to thematic analysis and quantitative data will be subject to descriptive statistical analysis. Qualitative and quantitative data will then be synthesised, which will enhance the rigour of this study, and pertinently inform the further development of an end-of-life skin care decision-making tool for patients with cancer. ETHICS AND DISSEMINATION Ethical approval to undertake the study has been granted by Cardiff University School of Healthcare Sciences Research Governance and Ethics Screening Committee. Informed consent will be obtained in writing from all the participants in this study. The results of this study will be disseminated through journal articles, as well as presentations at national and international conferences. We will also report our findings to patient and public involvement groups with an interest in improving cancer care, palliative care as well as skin care.
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Affiliation(s)
- Ray Samuriwo
- School of Healthcare Sciences, College of Biomedical and Life Sciences, Cardiff University, Cardiff, United Kingdom
- Wales Centre for Evidence Based Care, School of Healthcare Sciences, College of Biomedical and Life Sciences, Cardiff University, Cardiff, United Kingdom
| | | | - Sally Anstey
- School of Healthcare Sciences, College of Biomedical and Life Sciences, Cardiff University, Cardiff, United Kingdom
| | - Claire Job
- School of Healthcare Sciences, College of Biomedical and Life Sciences, Cardiff University, Cardiff, United Kingdom
| | - Jane Hopkinson
- School of Healthcare Sciences, College of Biomedical and Life Sciences, Cardiff University, Cardiff, United Kingdom
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Ponce KLP, Tejada-Tayabas LM, González YC, Haro OH, Zúñiga ML, Morán ACA. Nursing care for renal patients on hemodialysis: challenges, dilemmas and satisfactions. Rev Esc Enferm USP 2019; 53:e03502. [PMID: 31800805 DOI: 10.1590/s1980-220x2018011103502] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Accepted: 02/26/2019] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To identify the challenges, dilemmas and satisfactions presented by nursing professionals in hemodialysis services during the care of renal patients. METHOD Institutional ethnography was used, and 18 semi-structured interviews were conducted with nine members of the nursing staff. Conventional content analysis was performed. RESULTS For the nursing staff, care presents challenges such as the complex physical and emotional condition of patients, the management of technology for care, and coping with the suffering and death of patients with whom they have established a close relationship. The dilemmas are related to providing care for patients who refuse to receive it, and the personal and family costs involved in treatment in contrast to the limited quality of life of some patients. The main satisfactions are collaborative work, the sufficiency of resources and the confidence and recognition for performing independent work. CONCLUSION The findings of the study are associated with the presence of professional burnout and interference in the ability to build satisfactory interpersonal relationships, lower job satisfaction and quality of care.
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Affiliation(s)
- Karla Lizbeth Partida Ponce
- Instituto Mexicano del Seguro Social, Hospital General Núm. 2, Departamento de Medicina Preventiva, San Luis Potosí, S.L.P., México
| | | | - Yadira Chávez González
- Instituto de Seguridad Social al Servicio de los Trabajadores del Estado, Clínica de Especialidades, Departamento de Epidemiología, San Luis Potosí, S.L.P., México
| | - Ofelia Hernández Haro
- Instituto de Seguridad Social al Servicio de los Trabajadores del Estado, Clínica de Especialidades, Unidad de Hemodiálisis, San Luis Potosí, S.L.P., México
| | - Magdalena Lozano Zúñiga
- Universidad Michoacana de San Nicolás de Hidalgo, Facultad de Enfermería, Unidad de Posgrado, Morelia, Michoacán, México
| | - Ana Celia Anguiano Morán
- Universidad Michoacana de San Nicolás de Hidalgo, Facultad de Enfermería, Unidad de Posgrado, Morelia, Michoacán, México
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Richards CA, Hebert PL, Liu CF, Ersek M, Wachterman MW, Taylor LL, Reinke LF, O’Hare AM. Association of Family Ratings of Quality of End-of-Life Care With Stopping Dialysis Treatment and Receipt of Hospice Services. JAMA Netw Open 2019; 2:e1913115. [PMID: 31603487 PMCID: PMC6804019 DOI: 10.1001/jamanetworkopen.2019.13115] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 08/23/2019] [Indexed: 12/01/2022] Open
Abstract
Importance Approximately 1 in 4 patients receiving maintenance dialysis for end-stage renal disease eventually stop treatment before death. Little is known about the association of stopping dialysis and quality of end-of-life care. Objectives To evaluate the association of stopping dialysis before death with family-rated quality of end-of-life care and whether this association differed according to receipt of hospice services at the time of death. Design, Setting, and Participants This survey study included data from 3369 patients who were treated with maintenance dialysis at 111 Department of Veterans Affairs medical centers and died between October 1, 2009, to September 30, 2015. Data set construction and analyses were conducted from September 2017 to July 2019. Exposure Cessation of dialysis treatment before death. Main Outcomes and Measures Bereaved Family Survey ratings. Results Among 3369 patients included, the mean (SD) age at death was 70.6 (10.2) years, and 3320 (98.5%) were male. Overall, 937 patients (27.8%) stopped dialysis before death and 2432 patients (72.2%) continued dialysis treatment until death. Patients who stopped dialysis were more likely to have been receiving hospice services at the time of death than patients who continued dialysis (544 patients [58.1%] vs 430 patients [17.7%]). Overall, 1701 patients (50.5%) had a family member who responded to the Bereaved Family Survey. In adjusted analyses, families were more likely to rate overall quality of end-of-life care as excellent if the patient had stopped dialysis (54.9% vs 45.9%; risk difference, 9.0% [95% CI, 3.3%-14.8%]; P = .002) or continued to receive dialysis but also received hospice services (60.5% vs 40.0%; risk difference, 20.5% [95% CI, 12.2%-28.9%]; P < .001). Conclusions and Relevance This survey study found that families rated overall quality of end-of-life care higher for patients who stopped dialysis before death or continued dialysis but received concurrent hospice services. More work to prepare patients for end-of-life decision-making and to expand access to hospice services may help to improve the quality of end-of-life care for patients with end-stage renal disease.
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Affiliation(s)
- Claire A. Richards
- Health Services Research and Development, Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, US Department of Veterans Affairs, Seattle, Washington
- Department of Health Services, School of Public Health, University of Washington, Seattle
| | - Paul L. Hebert
- Health Services Research and Development, Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, US Department of Veterans Affairs, Seattle, Washington
- Department of Health Services, School of Public Health, University of Washington, Seattle
| | - Chuan-Fen Liu
- Health Services Research and Development, Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, US Department of Veterans Affairs, Seattle, Washington
- Department of Health Services, School of Public Health, University of Washington, Seattle
| | - Mary Ersek
- Corporal Michael J. Crescenz VA Medical Center–Philadelphia, Philadelphia, Pennsylvania
- School of Nursing, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Melissa W. Wachterman
- Veterans Affairs Boston Healthcare System, Boston, Massachusetts
- Dana-Farber Cancer Institute, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Leslie L. Taylor
- Health Services Research and Development, Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, US Department of Veterans Affairs, Seattle, Washington
| | - Lynn F. Reinke
- Health Services Research and Development, Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, US Department of Veterans Affairs, Seattle, Washington
- School of Nursing, Department of Biobehavioral Nursing and Health Informatics, University of Washington, Seattle
| | - Ann M. O’Hare
- Health Services Research and Development, Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, US Department of Veterans Affairs, Seattle, Washington
- University of Washington School of Medicine, Seattle
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O'Riordan J, Noble H, Kane PM, Smyth A. Advance care plan barriers in older patients with end-stage renal disease: a qualitative nephrologist interview study. BMJ Support Palliat Care 2019; 10:e39. [PMID: 31239255 DOI: 10.1136/bmjspcare-2018-001759] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 03/28/2019] [Accepted: 04/22/2019] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Older patients with end-stage renal disease are willing participants in advance care planning but just over 10% are engaged in this process. Nephrologists fear such conversations may upset patients and so tend to avoid these discussions. This approach denies patients the opportunity to discuss their end-of-life care preferences. Many patients endure medically intensive end-of-life scenarios as a result. This study aims to explore the rationale underpinning nephrologists' clinical decision-making in the management of older patients with end-stage renal disease and to make recommendations that inform policymakers and enhance advance care planning for this patient group. METHODS A qualitative interview study of 20 nephrologists was undertaken. Nephrologists were asked about their management of end-stage renal disease in older patients, conservative management, dialysis withdrawal and end-of-life care. Eligible participants were nephrologists working in Ireland. Five nephrologists participated in a recorded focus group and 15 nephrologists participated in individual digitally recorded telephone interviews. Semistructured interviews were conducted; thematic analysis was used to distil the results. RESULTS Three key themes emerged: barriers to advance care planning; barriers to shared decision-making; and avoidance of end-of-life care discussion. CONCLUSIONS Advance care planning is not an integral part of the routine care of older patients with end-stage renal disease. Absence of formal training of nephrologists in how to communicate with patients contributes to poor advance care planning. Nephrologists lack clinical experience of conservatively managing end-stage renal disease and end-of-life care in older patients. Key policy recommendations include formal communication skills training for nephrologists and development of the conservative management service.
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Affiliation(s)
- Julien O'Riordan
- Palliative Medicine, Galway University Hospitals, Galway, Ireland .,College of Medicine, Nursing and Health Sciences, National University of Ireland, Galway, Ireland
| | - Helen Noble
- School of Nursing and Midwifery, Queen's University Belfast, Belfast, UK
| | - P M Kane
- Palliative Medicine, Specialist Community Palliative Care Services, Health Service Executive (HSE), Laois/ Offaly and Longford/ Westmeath, Ireland
| | - Andrew Smyth
- Clinical Research Facility, National University of Ireland, Galway, Ireland.,Nephrology, Galway University Hospitals, Galway, Ireland
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Axelsson L, Benzein E, Lindberg J, Persson C. Processes toward the end of life and dialysis withdrawal Physicians' and nurses' perspectives. Nurs Ethics 2019; 27:419-432. [PMID: 31185802 DOI: 10.1177/0969733019848050] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Nurses and physicians in nephrology settings provide care for patients with end-stage kidney disease receiving hemodialysis treatment along a complex illness trajectory. AIM The aim was to explore physicians' and nurses' perspectives on the trajectories toward the end of life involving decisions regarding hemodialysis withdrawal for patients with end-stage kidney disease. RESEARCH DESIGN AND PARTICIPANTS A qualitative research approach was used. Four mixed focus group interviews were conducted with renal physicians (5) and nurses (17) in Sweden. Qualitative content analysis was used to analyse data. ETHICAL CONSIDERATIONS Ethical approval was obtained (Dnr 2014/304-31). FINDINGS AND DISCUSSION Findings illuminated multi-faceted, intertwined processes encompassing healthcare professionals, patients, and family members. The analysis resulted in four themes: Complexities of initiating end-of-life conversations, Genuine attentiveness to the patient's decision-making process, The challenge awaiting the family members' processes, and Negotiating different professional responsibilities. Findings showed complexities and challenges when striving to provide good, ethical care which are related to beneficence, nonmaleficence, and self-determination, and which can give rise to moral distress. CONCLUSION There are ethical challenges and strains in the dialysis context that healthcare professionals may not always be prepared for. Supporting healthcare professionals in not allowing complexities to hinder the patient's possibilities for shared decision-making seems important. An open and continual communication, including family meetings, from dialysis initiation could serve to make conversations involving decisions about hemodialysis withdrawal a more natural routine, as well as build up a relationship of trust necessary for the advance care planning about the end of life. Healthcare professionals should also receive support in ethical reasoning to meet these challenges and handle potential moral distress in the dialysis context.
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Affiliation(s)
| | | | - Jenny Lindberg
- Lund University, Sweden; Skåne University Hospital, Sweden
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Wetmore JB, Roetker NS, Gilbertson DT, Liu J. Early withdrawal and non-withdrawal death in the months following hemodialysis initiation: A retrospective cohort analysis. Hemodial Int 2019; 23:261-272. [PMID: 30741471 PMCID: PMC7032605 DOI: 10.1111/hdi.12723] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 11/12/2018] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Whether and how factors associated with elective hemodialysis withdrawal differ from those associated with non-withdrawal death soon after maintenance hemodialysis initiation have not been well studied. METHODS A retrospective cohort analysis was performed using USRDS data from 2011 to 2014. Patients were randomly categorized 2:1 into training and validation samples. Elective withdrawal deaths were identified using the Death Notification form. Multinomial logistic regression was used to fit a prediction model for three outcome categories (withdrawal, non-withdrawal death, survival at 6 months) as a function of demographic, comorbidity, and functional status. FINDINGS The training sample comprised 80,284 hemodialysis patients. Mean age was 71.7 ± 11.4 years, 44.9% were female, 72.9% were white, and 22.8% were black. Within 6 months, 19.1% died, of whom 2099 (2.6%) withdrew and 13,223 (16.5%) died of a non-withdrawal cause; 13.7% of all deaths were withdrawals. Baseline characteristics and event rates were similar among the 40,142 patients in the validation sample. The model was calibrated adequately and could discriminate moderately well between withdrawal and survival (area under ROC curve [AUC]: 0.77) and between non-withdrawal death and survival (AUC: 0.73). However, discrimination between withdrawal and non-withdrawal death was relatively low (AUC: 0.62). Older age and white, compared with non-white, race were each associated with greater odds of death, and these associations were stronger for withdrawal than for non-withdrawal death. DISCUSSION Advanced age and white, as opposed to black, race were most strongly associated with early elective hemodialysis withdrawal compared with non-withdrawal death. However, it is difficult to differentiate between patients who will experience early withdrawal vs. non-withdrawal death, as many factors are similarly associated with both outcomes.
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Affiliation(s)
- James B. Wetmore
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
- Division of Nephrology, Hennepin Healthcare Systems, University of Minnesota, Minneapolis, Minnesota
| | - Nicholas S. Roetker
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
| | - David T. Gilbertson
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
| | - Jiannong Liu
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
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Ni P, Ko E, Mao J. Preferences for Feeding Tube Use and Their Determinants Among Cognitively Intact Nursing Home Residents in Wuhan, China: A Cross-Sectional Study. J Transcult Nurs 2019; 31:13-21. [PMID: 30810098 DOI: 10.1177/1043659619832078] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Introduction: Standard advance care planning practice is yet to be established in Mainland, China, and little is known about feeding tube preferences among Chinese nursing home residents. The purpose of the study was to examine preferences for feeding tube use and its predictors among frail and cognitively competent nursing home residents in Wuhan, China. Method: A cross-sectional sample of 682 nursing home residents were interviewed face-to-face using a structured questionnaire from 2012 to 2014. Results: A total of 54.5% of participants would accept feeding tube. Participants who reported greater quality of life (odds ratio [OR] = 2.67), having health insurance (OR = 2.09) were more willing to accept feeding tube. Participants with greater impairment in physical health (OR = 0.94) were less willing to accept it. Discussion: Health care professionals need to routinely assess nursing home residents' feeding tube preferences. It is imperative to consider sociocultural perspectives in understanding Chinese older adults' decision making for end-of-life care.
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Affiliation(s)
- Ping Ni
- Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Eunjeong Ko
- San Diego State University, San Diego, CA, USA
| | - Jing Mao
- Huazhong University of Science and Technology, Wuhan, Hubei, China
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Naylor KL, Kim SJ, McArthur E, Garg AX, McCallum MK, Knoll GA. Mortality in Incident Maintenance Dialysis Patients Versus Incident Solid Organ Cancer Patients: A Population-Based Cohort. Am J Kidney Dis 2019; 73:765-776. [PMID: 30738630 DOI: 10.1053/j.ajkd.2018.12.011] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 12/03/2018] [Indexed: 12/30/2022]
Abstract
RATIONALE & OBJECTIVE The mortality rate is high among dialysis patients, but how this compares with other diseases such as cancer is poorly understood. We compared the survival of maintenance dialysis patients with that for patients with common cancers to enhance the understanding of the burden of end-stage kidney disease. STUDY DESIGN Population-based cohort study. SETTING & PARTICIPANTS 33,500 incident maintenance dialysis patients in Ontario, Canada, and 532,452 incident patients with cancer (women: breast, colorectal, lung, or pancreas; men: prostate, colorectal, lung, or pancreas) from 1997 to 2015 using administrative health care databases. EXPOSURE Incident kidney failure treated with maintenance dialysis versus incident diagnoses of cancer. OUTCOME All-cause mortality. ANALYTICAL APPROACH Kaplan-Meier product limit estimator was used to describe the survival of subgroups of study participants. Extended Cox regression with a Heaviside function was used to compare survival between patients with incident kidney failure treated with maintenance dialysis and individual diagnoses of various incident cancers. RESULTS In men, dialysis had worse unadjusted 5-year survival (50.8%; 95% CI, 50.1%-51.6%) compared with prostate (83.3%; 95% CI, 83.1%-83.5%) and colorectal (56.1%; 95% CI, 55.7%-56.5%) cancer, but better survival than lung (14.0%; 95% CI, 13.7%-14.3%) and pancreas (9.1%; 95% CI, 8.5%-9.7%) cancer. In women, dialysis had worse unadjusted 5-year survival (49.8%; 95% CI, 48.9%-50.7%) compared with breast (82.1%; 95% CI, 81.9%-82.4%) and colorectal (56.8%; 95% CI, 56.3%-57.2%) cancer, but better survival than lung (19.7%; 95% CI, 19.4%-20.1%) and pancreas (9.4%; 95% CI, 8.9%-10.0%) cancer. After adjusting for clinical characteristics, similar results were found except when examining men and women with lung and pancreas cancer, for which dialysis patients had a higher rate of death 4 or more years after diagnosis. Women and men 70 years and older with incident kidney failure treated with maintenance dialysis had unadjusted 10-year survival probabilities that were comparable to pancreas and lung cancer. LIMITATIONS Cancer stage could be obtained for only a subpopulation. CONCLUSIONS Survival in incident dialysis patients was lower than in patients with several different solid-organ cancers. These results highlight the need to develop interventions to improve survival on dialysis therapy and can be used to aid advance care planning for elderly patients beginning treatment with maintenance dialysis.
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Affiliation(s)
- Kyla L Naylor
- ICES, London, Ontario, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - S Joseph Kim
- ICES, London, Ontario, Canada; Division of Nephrology, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | | | - Amit X Garg
- ICES, London, Ontario, Canada; Division of Nephrology, Western University, London, Ontario, Canada; Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | | | - Gregory A Knoll
- Division of Nephrology, Department of Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, Ontario, Canada; Kidney Research Centre and Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.
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Alshamsi FE, Chaaban A, Alrukhaimi M, Bernieh B, Bakoush O. Provision of renal care for patients with end stage kidney disease in persistent vegetative state, in United Arab Emirates: a national survey of renal physicians. Libyan J Med 2018; 13:1490610. [PMID: 29979643 PMCID: PMC6041784 DOI: 10.1080/19932820.2018.1490610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/29/2022] Open
Abstract
Patients with end stage kidney disease (ESKD) with severely impaired cognitive function have no survival benefit from dialysis. We therefore undertook a survey to explore the renal physicians' practices of withholding and withdrawal of dialysis treatment in vegetative state patients in the United Arab Emirates (UAE). A cross sectional survey of 29 nephrology practices in UAE exploring physicians' practices in making decisions of withholding and withdrawal of dialysis treatment during provision end-of-life care for patients in persistent vegetative state (PVS).The majority of participants practice in governmental non-for-profit dialysis units (79%), and think they are well prepared to make decision with patients and family on issues of dialysis withdrawal and withholding (69%). If a chronic dialysis patient became permanently unconscious only few respondents (17%) indicated probability of stopping dialysis. On the other hand, more respondents (48%) reported that dialysis is likely to be withheld in PVS patients who develop kidney failure. In high risk or poor prognosis ESKD patients and given how likely they would consider each option independently, respondents reported they are likely to consider time-limited dialysis in 78% of the time followed by stopping (46%) or forgoing (27%) dialysis. Majority of the participants perceived that their decisions in providing renal care for PVS patients in UAE were influenced by the family sociocultural beliefs (76% of participants), the current hospital policies (72% of participants), and by Islamic beliefs (66% of participants). Only few perceived access to palliative care (30%) and treatment cost (17%) to have an impact on their decision making.Decisions of initiation and continuation of dialysis treatment to ESKD patients in PVS are prevalent among nephrology practices in UAE. Development of local guidelines based on the societal values along with early integration of palliative kidney failure management care would be required to improve the quality of provision of end-of-life renal care in UAE. ABBREVIATIONS ESKD: stage kidney disease; UAE: United Arab Emirates; PVS: persistent vegetative state; RPA: Renal Physicians Association; ASN: American Society of Nephrology; EMAN: Emirates Medical Association Nephrology Society; CPR: cardiopulmonary resuscitation.
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Affiliation(s)
| | - Ahmed Chaaban
- b Nephrology Department , Tawam Hopsital , United Arab Emirates
| | - Mona Alrukhaimi
- c Department of Internal Medicine , Dubai Medical College , Dubai , United Arab Emirates
| | - Bassam Bernieh
- b Nephrology Department , Tawam Hopsital , United Arab Emirates
| | - Omran Bakoush
- a College of Medicine , United Arab Emirates University , United Arab Emirates
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Axelsson L, Alvariza A, Lindberg J, Öhlén J, Håkanson C, Reimertz H, Fürst CJ, Årestedt K. Unmet Palliative Care Needs Among Patients With End-Stage Kidney Disease: A National Registry Study About the Last Week of Life. J Pain Symptom Manage 2018; 55:236-244. [PMID: 28941964 DOI: 10.1016/j.jpainsymman.2017.09.015] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 09/09/2017] [Accepted: 09/12/2017] [Indexed: 11/28/2022]
Abstract
CONTEXT End-stage kidney disease (ESKD) is characterized by high physical and psychological burden, and therefore, more knowledge about the palliative care provided close to death is needed. OBJECTIVES To describe symptom prevalence, relief, and management during the last week of life, as well as end-of-life communication, in patients with ESKD. METHODS This study was based on data from the Swedish Register of Palliative Care. Patients aged 18 or older who died from a chronic kidney disease, with or without dialysis treatment (International Classification of Diseases, Tenth Revision, Sweden; N18.5 or N18.9), during 2011 and 2012 were selected. RESULTS About 472 patients were included. Of six predefined symptoms, pain was the most prevalent (69%), followed by respiratory secretion (46%), anxiety (41%), confusion (30%), shortness of breath (22%), and nausea (17%). Of patients with pain and/or anxiety, 32% and 44%, respectively, were only partly relieved or not relieved at all. Of patients with the other symptoms, a majority (55%-84%) were partly relieved or not relieved at all. End-of-life discussions were reported in 41% of patients and 71% of families. A minority died in specialized palliative care: 8% in hospice/inpatient palliative care and 5% in palliative home care. Of all patients, 19% died alone. Bereavement support was offered to 38% of families. CONCLUSION Even if death is expected, most patients dying with ESKD had unmet palliative care needs regarding symptom management, advance care planning, and bereavement support.
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Affiliation(s)
- Lena Axelsson
- Center for Collaborative Palliative Care, Faculty of Health and Life Sciences, Linnaeus University, Kalmar, Sweden; Sophiahemmet University, Stockholm, Sweden.
| | - Anette Alvariza
- Department of Health Care Sciences, Palliative Research Centre, Ersta Sköndal University College, Stockholm, Sweden; Capio Palliative Care Unit, Dalen Hospital, Stockholm, Sweden
| | - Jenny Lindberg
- Unit of Medical Ethics, Department of Clinical Sciences, Faculty of Medicine, Lund University, Lund, Sweden; Department of Nephrology, Skåne University Hospital, Malmö, Sweden
| | - Joakim Öhlén
- Centre for Person-Centred Care and Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Cecilia Håkanson
- Department of Nursing Science, Sophiahemmet University, Stockholm, Sweden
| | - Helene Reimertz
- Center for Collaborative Palliative Care, Växjö, Sweden; Unit of Palliative Care, Region Kronoberg, Växjö, Sweden
| | - Carl-Johan Fürst
- The Institute for Palliative Care, Lund University and Region Skåne, Lund, Sweden
| | - Kristofer Årestedt
- Faculty of Health and Life Sciences, Linnaeus University, Kalmar, Sweden; Department of Research, Kalmar County Hospital, Kalmar, Sweden
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Wetmore JB, Yan H, Hu Y, Gilbertson DT, Liu J. Factors Associated With Withdrawal From Maintenance Dialysis: A Case-Control Analysis. Am J Kidney Dis 2018; 71:831-841. [PMID: 29331476 DOI: 10.1053/j.ajkd.2017.10.025] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Accepted: 10/30/2017] [Indexed: 01/03/2023]
Abstract
BACKGROUND Little is known about differences in the clinical course between patients receiving maintenance dialysis who do and do not withdraw from dialysis therapy. STUDY DESIGN Case-control analysis. SETTING & PARTICIPANTS US patients with Medicare coverage who received maintenance hemodialysis for 1 year or longer in 2008 through 2011. PREDICTORS Comorbid conditions, hospitalizations, skilled nursing facility stays, and a morbidity score based on durable medical equipment claims. OUTCOME Withdrawal from dialysis therapy. MEASUREMENTS Rates of medical events, hospitalizations, skilled nursing facility stays, and a morbidity score. RESULTS The analysis included 18,367 (7.7%) patients who withdrew and 220,443 (92.3%) who did not. Patients who withdrew were older (mean age, 75.3±11.5 [SD] vs 66.2±14.1 years) and more likely to be women and of white race, and had higher comorbid condition burdens. The odds of withdrawal among women were 7% (95% CI, 4%-11%) higher than among men. Compared to age 65 to 74 years, age 85 years or older was associated with higher adjusted odds of withdrawal (adjusted OR, 1.61; 95% CI, 1.54-1.68), and age 18 to 44 years with lower adjusted odds (adjusted OR, 0.36; 95% CI, 0.32-0.40). Blacks, Asians, and Hispanics were less likely to withdraw than whites (adjusted ORs of 0.36 [95% CI, 0.35-0.38], 0.47 [95% CI, 0.42-0.53], and 0.46 [95% CI, 0.44-0.49], respectively). A higher durable medical equipment claims-based morbidity score was associated with withdrawal, even after adjustment for traditional comorbid conditions and hospitalization; compared to a score of 0 (lowest presumed morbidity), adjusted ORs of withdrawal were 3.48 (95% CI, 3.29-3.67) for a score of 3 to 4 and 12.10 (95% CI, 11.37-12.87) for a score ≥7. Rates of medical events and institutionalization tended to increase in the months preceding withdrawal, as did morbidity score. LIMITATIONS Results may not be generalizable beyond US Medicare patients; people who withdrew less than 1 year after dialysis therapy initiation were not studied. CONCLUSIONS Women, older patients, and those of white race were more likely to withdraw from dialysis therapy. The period before withdrawal was characterized by higher rates of medical events and higher levels of morbidity.
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Affiliation(s)
- James B Wetmore
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, MN; Division of Nephrology, Hennepin County Medical Center, University of Minnesota, Minneapolis, MN.
| | - Heng Yan
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, MN
| | - Yan Hu
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, MN
| | - David T Gilbertson
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, MN
| | - Jiannong Liu
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, MN
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Sellars M, Tong A, Luckett T, Morton RL, Pollock CA, Spencer L, Silvester W, Clayton JM. Clinicians' Perspectives on Advance Care Planning for Patients With CKD in Australia: An Interview Study. Am J Kidney Dis 2017; 70:315-323. [PMID: 28216281 DOI: 10.1053/j.ajkd.2016.11.023] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Accepted: 11/27/2016] [Indexed: 11/11/2022]
Abstract
BACKGROUND Advance care planning (ACP) empowers patients to consider and communicate their current and future treatment goals. However, ACP is not widely implemented in chronic kidney disease (CKD) care settings. This study aims to describe clinicians' beliefs, challenges, and perspectives of ACP in patients with CKD. STUDY DESIGN Qualitative study. SETTING & PARTICIPANTS Nephrologists (n=20), nurses (n=7), and social workers (n=4) with a range of experience in facilitating ACP for patients with CKD across Australia. METHODOLOGY Semistructured interviews were digitally recorded and transcribed verbatim. ANALYTICAL APPROACH Transcripts were analyzed using thematic analysis. RESULTS 5 major themes were identified: facilitating informed decision making (avoiding preconceptions, conveying complete truths, focusing on supportive care, and synchronizing with evolving priorities), negotiating moral boundaries (contending with medical futility and respecting patient vs family autonomy), navigating vulnerable conversations (jeopardizing the therapeutic relationship, compromising professional confidence, emotionally invested, and enriching experiences), professional disempowerment (unsupportive culture, doubting logistical feasibility, and making uncertain judgments), and clarifying responsibilities (governing facilitation, managing tensions, and transforming multidisciplinary relationships). LIMITATIONS Some findings may be specific to the Australian context. CONCLUSIONS The tensions among themes reflect that ACP is paradoxically rewarding for clinicians because ACP empowers patients yet can expose personal and professional vulnerabilities. Clinicians believe that a more collaborative approach is needed, with increased efforts to identify the evolving and individualized needs and goals of patients with CKD. Models of ACP that address clinicians' personal and professional vulnerabilities when initiating ACP may foster greater confidence and cultural acceptance of ACP in the CKD setting.
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Affiliation(s)
- Marcus Sellars
- Sydney Medical School, The University of Sydney, Sydney, Australia
| | - Allison Tong
- Sydney School of Public Health, The University of Sydney, Sydney, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, Australia
| | - Tim Luckett
- Improving Palliative Care through Clinical Trials (ImPaCCT) New South Wales, Australia; Faculty of Health, University of Technology Sydney (UTS), Australia
| | - Rachael L Morton
- NHMRC Clinical Trials Centre, The University of Sydney, Australia
| | - Carol A Pollock
- Sydney Medical School, The University of Sydney, Sydney, Australia; Department of Renal Medicine, Royal North Shore Hospital, Australia
| | - Lucy Spencer
- NHMRC Clinical Trials Centre, The University of Sydney, Australia
| | | | - Josephine M Clayton
- Sydney Medical School, The University of Sydney, Sydney, Australia; Improving Palliative Care through Clinical Trials (ImPaCCT) New South Wales, Australia; HammondCare Palliative & Supportive Care Service, Greenwich Hospital, Sydney, Australia.
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