An appraisal of end-of-life care in persons with chronic kidney disease dying in hospital wards

Fim de vida na doença renal terminal: fatores associados ao local de óbito num programa de cuidados paliativos

Resumo Introdução: Os cuidados de fim de vida em doentescom doença renal terminal (DRT) podem ser desafiantes e necessitar do apoio de uma equipa especializada em cuidados paliativos (ECP). Objetivo: Caracterizar a população de doentes com DRT encaminhada à ECP e avaliar os determinantes para um fim de vida planeado no domicílio. Métodos: Realizámos um estudo de coorte observacional retrospectivo dos doentes com DRT encaminhados à ECP entre janeiro/2014 e dezembro/2021 (n = 60) e caracterizámos aqueles com DRT previamente conhecida relativamente ao local de fim de vida (n = 53). Resultados: A maioria dos pacientes eram mulheres comidade mediana de 84 anos. Metade dos doentes encontrava-se em tratamento conservador, 43% em hemodiálise crónica e os restantes suspenderam diálise iniciada agudamente. Daqueles com DRT previamente conhecida, 18% morreram em casa. Não foi objetivada associação entre género, idade, cognição, status funcional, comorbilidades, etiologia da DRC ou modalidade de tratamento da DRT e o local de óbito. A anúria e a menor sobrevida após suspensão de diálise associaram-se a um fim de vida no hospital e verificámos uma tendência para o fim de vida em casa nos doentes com mais tempo de acompanhamento pela ECP. Conclusão: O fim de vida no domicílio é possível num programa domiciliário de cuidados paliativos, independentemente de idade, sexo, etiologia da DRC, principais comorbilidades e modalidade de tratamento. A anúria e o menor tempo de sobrevida após suspensão da TRS podem ser fatores limitantes. Um acompanhamento mais longo em cuidados paliativos pode favorecer o fim de vida no domicílio.

Dying with end stage kidney disease: factors associated with place of death on a palliative care program

INTRODUCTION

End of life care of patients with end-stage kidney disease (ESKD) may be particularly challenging and requires the intervention of a specialized palliative care team (PCT).

OBJECTIVE

To characterize the population of ESKD patients referred to a PCT and evaluate the determinants of planned dying at home.

METHODS

We performed a retrospective observational cohort study of all patients with ESKD referred to our PCT between January 2014 and December 2021 (n = 60) and further characterized those with previously known ESKD regarding place of death (n = 53).

RESULTS

The majority of the patients were female and the median age was 84 years. Half of the patients were on conservative treatment, 43% were on chronic hemodialysis, and the remainder underwent hemodialysis on a trial basis and were subsequently suspended. Of those with previously known ESKD, 18% died at home and neither gender, age, cognition, performance status, comorbidities, CKD etiology, or treatment modality were associated with place of death. Anuria was significantly associated with dying at the hospital as was shorter time from dialysis suspension and death. Although not reaching statistical significance, we found a tendency towards a longer duration of palliative care follow-up in those dying at home.

CONCLUSION

Dying at home is possible in a palliative domiciliary program regardless of age, gender, etiology of CKD, major comorbidities, and treatment modality. Anuria and shorter survival from RRT withdrawal may be limiting factors for planned dying at home. A longer follow-up by palliative care may favor dying at home.

Development of an emergency department end of life care audit tool: A scoping review

Introduction

Emergency departments frequently care for patients at the end of life and should have robust processes for reviewing delivery of care. The aim of this scoping review is to examine and collate the chart audit tools available to assess the quality of end of life care of patients who die in the emergency department, or, in the subsequent hospital admission.

Methods

A scoping review of the literature using the PRISMA-ScR (Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews) guidelines, and the methodological framework outlined by Arksey and O'Malley was conducted. Primary and secondary research, along with grey literature were searched. Both adult and paediatric populations were included. Databases Ovid Emcare, CINAHL and Medline were searched from 1961 to December 2022; followed by screening and appraisal. Articles were compared and data synthesised into categories.

Results

Fifty-eight articles were included generating three categories; contexts for end of life audit use, development and evaluation of audit tools, and audit characteristics / components. Four tools focused on the emergency department, however, did not comprehensively review both end of life and emergency department specific data. A draft audit tool for the emergency department was developed that consisted of the common elements to evaluate end of life care as identified in this review, emergency department-specific quality of care measures and the integration of the Criteria for Screening and Triaging to Appropriate aLternative care (CriSTAL) tool.

Conclusion

No audit tool to comprehensively review end of life care provided for patients at the end of life in the emergency department was found. We developed an audit tool based on best available evidence that now needs testing for validity, feasibility, and usability to evaluate end of life in the emergency department setting is required.

Living with dying: A narrative inquiry of people with chronic kidney disease and their family members

Aims

To describe how people diagnosed with chronic kidney disease and their family members describe uncertainty related to impending death.

Background

There has been little research about the experiences of people with chronic kidney disease and their family members as they near the end‐of‐life. We need to understand these experiences to give holistic person‐centred care.

Design

A narrative enquiry was undertaken using a social constructionist perspective.

Methods

Data were collected in two in‐depth interviews, approximately 3–4 months apart, followed by a telephone follow‐up 2–3 months later.

Results

Eleven people with advanced chronic kidney disease and nine family members/significant others participated. For both participants in the dyad, a number of key themes/storylines were identified. These included recognition that: @life has a boundary, living on the edge, I'm not afraid to die but… and remembering loss and death experiences@.

Conclusions

This enquiry illuminated four key storylines of about death and dying with advanced chronic kidney disease for people with the illness and their family members. Discussion about past experiences with illness, loss, death, and dying can give an entry for discussion about end‐of‐life. The person with illness and family members often held very similar perceptions and desires, but healthcare professionals’ contributions to understanding of the experience were not mentioned. Implications for clinicians include attending to peoples’ awareness of death as a distinct opportunity, listening attentively and posing questions that genuinely invite concerns and wishes about end–of‐life and living well.

"Maybe They Don't Even Know That I Exist": Challenges Faced by Family Members and Friends of Patients with Advanced Kidney Disease

BACKGROUND AND OBJECTIVES

Family members and friends of patients with advanced chronic illness are increasingly called on to assist with ever more complex medical care and treatment decisions arising late in the course of illness. Our goal was to learn about the experiences of family members and friends of patients with advanced kidney disease.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

As part of a study intended to identify opportunities to enhance advance care planning, we conducted semistructured interviews at the Veterans Affairs Puget Sound Health Care System with 17 family members and friends of patients with advanced kidney disease. Interviews were conducted between April of 2014 and May of 2016 and were audiotaped, transcribed, and analyzed inductively using grounded theory to identify emergent themes.

RESULTS

The following three themes emerged from interviews with patients' family members and friends: (1) their roles in care and planning were fluid over the course of the patient's illness, shaped by the patients' changing needs and their readiness to involve those close to them; (2) their involvement in patients' care was strongly shaped by health care system needs. Family and friends described filling gaps left by the health care system and how their involvement in care and decision-making was at times constrained and at other times expected by providers, depending on system needs; and (3) they described multiple sources of tension and conflict in their interactions with patients and the health care system, including instances of being pitted against the patient.

CONCLUSIONS

Interviews with family members and friends of patients with advanced kidney disease provide a window on the complex dynamics shaping their engagement in patients' care, and highlight the potential value of offering opportunities for engagement throughout the course of illness.

Spirituality in Renal Supportive Care: A Thematic Review

Chronic kidney disease is marked by a reduced life expectancy and a high symptom burden. For those who reach end-stage renal disease, the prognosis is poor, and this combined with the growing prevalence of the disease necessitates supportive and palliative care programmes that will address people's psychosocial, cultural and spiritual needs. While there is variation between countries, research reveals that many renal specialist nurses and doctors are reluctant to address spirituality, initiate end-of-life conversations or implement conservative treatment plans early. Yet, other studies indicate that the provision of palliative care services, which includes the spiritual dimension, can reduce symptom burden, assist patients in making advanced directives/plans and improve health-related quality of life. This review brings together the current literature related to renal supportive care and spirituality under the following sections and themes. The introduction and background sections situate spirituality in both healthcare generally and chronic kidney disease. Gaps in the provision of chronic kidney disease spiritual care are then considered, followed by a discussion of the palliative care model related to chronic kidney disease and spirituality. Chronic kidney disease spiritual needs and care approaches are discussed with reference to advanced care planning, hope, grief and relationships. A particular focus on quality of life is developed, with spirituality named as a key dimension. Finally, further challenges, such as culture, training and limitations, are explicated.