Renal supportive care, palliative care and end-of-life care: Perceptions of similarities, differences and challenges across Australia and New Zealand

"You don't want to know just about my lungs, you…want to know more about me". Patients and their caregivers' evaluation of a nurse-led COPD supportive care service

AIM

To evaluate a nurse-led model of supportive care in a COPD outpatient service from patient and caregiver perspectives.

DESIGN

Case study methodology.

METHODS

Data were collected from semi-structured interviews with patients (n = 12) and caregivers (n = 7) conducted between April 2020 and September 2022. A purposive sampling strategy was used. Interviews were transcribed verbatim and analysed using content analysis with an inductive approach. COREQ guidelines informed reporting of this study.

RESULTS

Eight categories were identified from the data evaluating of the model of care relating to the most helpful aspects of COPD supportive care and suggested improvements to the model of care. The categories were: guidance with managing symptoms; participating in advance care planning; home visiting; expert advice; continuity and trust; caring; caregiver support and improvements to the model of care.

CONCLUSION

In a nurse-led model of COPD supportive care, what patients and caregivers valued most was expert advice and guidance with symptom management, flexible home visiting, participation in advance care planning, caring and continuity within an ongoing trusted therapeutic relationship. Understanding what patients and caregivers value most is essential in designing and delivering models of care that meet the needs of patients living with chronic, life-limiting illness.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Nurses can lead effective models of supportive care that offer valuable support to patients living with COPD and their caregivers.

Advance care planning for patients with end-stage kidney disease on dialysis: narrative review of the current evidence, and future considerations

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.

Economic evaluation of dialysis and comprehensive conservative care for chronic kidney disease using the ICECAP-O and EQ-5D-5L; a comparison of evaluation instruments

BACKGROUND

Chronic Kidney Disease (CKD) patients often require long-term care, and while Hemodialysis (HD) is the standard treatment, Comprehensive Conservative Care (CCC) is gaining popularity as an alternative. Economic evaluations comparing their cost-effectiveness are crucial. This study aims to perform a cost-utility analysis comparing HD and CCC using the EQ-5D-5L and ICECAP-O instruments to assessing healthcare interventions in CKD patients.

METHODS

This short-term economic evaluation involved 183 participants (105 HD, 76 CCC) and collected data on demographics, comorbidities, laboratory results, treatment costs, and HRQoL measured by ICECAP-O and EQ-5D-5L. Incremental Cost-Effectiveness Ratios (ICERs) and Net Monetary Benefit (NMB) were calculated separately for each instrument, and Probabilistic Sensitivity Analysis (PSA) assessed uncertainty.

RESULTS

CCC demonstrated significantly lower costs (mean difference $8,544.52) compared to HD. Both EQ-5D-5L and ICECAP-O indicated higher Quality-Adjusted Life Years (QALYs) for both groups, but the difference was not statistically significant (p > 0.05). CCC dominated HD in terms of HRQoL measures, with ICERs of -$141,742.67 (EQ-5D-5L) and -$4,272.26 (ICECAP-O). NMB was positive for CCC and negative for HD, highlighting its economic feasibility.

CONCLUSION

CCC proves a preferable and more cost-effective treatment option than HD for CKD patients aged 65 and above, regardless of the quality-of-life measure used for QALY calculations. Both EQ-5D-5L and ICECAP-O showed similar results in cost-utility analysis.

Referral Criteria to Specialist Palliative Care for People with Advanced Chronic Kidney Disease: A Systematic Review

CONTEXT

People with advanced chronic kidney disease (CKD) have significant morbidity, yet for many, access to palliative care occurs late, if at all.

OBJECTIVES

This study sought to examine criteria for referral to specialist palliative care for adults with advanced CKD with a view to improving use of these essential services.

METHODS

Systematic review of studies detailing referral criteria to palliative care in advanced CKD conducted and reported according to the Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) guideline and registered (PROSPERO: CRD42021230751).

DATA SOURCES

Electronic databases (Ovid, MEDLINE, Ovid Embase, and PubMed) were used to identify potential studies, which were subjected to double review, data extraction, thematic coding, and descriptive analyses.

RESULTS

Searches yielded 650 unique titles ultimately resulting in 56 studies addressing referral criteria to specialist palliative care in advanced CKD. Of 10 categories of referral criteria, most commonly discussed were: Critical times of treatment decision making (n = 23, 41%); physical or emotional symptoms (n = 22, 39%); limited prognosis (n = 18, 32%); patient age and comorbidities (n = 18, 32%); category of CKD/ biochemical criteria (n = 13, 23%); functional decline (n = 13, 23); psychosocial needs (n = 9, 16%); future care planning (n = 9, 16%); anticipated decline in illness course (n = 8, 14%); and hospital use (n = 8, 14%).

CONCLUSION

Clinicians consider referral to specialist palliative care for a wide range of reasons, with many related to care needs. As palliative care continues to integrate with nephrology, our findings represent a key step towards developing consensus criteria to standardize referral for patients with chronic kidney diseases.

Perceptions and attitudes of kidney supportive care among elderly patients with advanced chronic kidney disease and dialysis healthcare professionals in China: a qualitative study

PURPOSE

Kidney supportive care (KSC) represents a novel approach wherein a multidisciplinary team of nephrology experts offers active symptom management, advance care planning, shared decision-making, conservative treatment, and end-of-life care. This study is aimed at providing comprehensive insights and evaluations regarding the understanding and perspectives of Chinese healthcare professionals, including nephrologists and dialysis nurses, as well as elderly individuals aged 60 and above who are afflicted with chronic kidney disease. The primary goal is to furnish substantial information support for a better comprehension of KSC within the Chinese context, with the ultimate aim of facilitating its effective implementation in this region.

METHODS

Employing a phenomenological framework, this qualitative research generated data using semi-structured interviews with 18 elderly patients diagnosed with advanced chronic kidney disease and 10 healthcare professionals across two Class III Grade A medical institutions. The Colaizzi's analytical method was utilized for coding and analyzing the interview data.

RESULTS

Distinct interviews were executed with patients and healthcare professionals to delineate specific themes for each group. For elderly dialysis patients, the following themes were formed: (1) Lack of understanding of KSC; (2) Concerns of how KSC is perceived; and (3) Perceived benefits of KSC. Within the healthcare professionals cohort, two salient themes emerged: (1) Prospective clinical merits of KSC ; and (2) Mltiple difficulties encountered.

CONCLUSIONS

This study goes some way in furnishing a holistic understanding of perceptions surrounding KSC among elderly patients undergoing dialysis and healthcare professionals in China. The overarching Chinese cultural ethos poses substantial challenges to the widespread assimilation of KSC. While healthcare professionals advocate for KSC, there remains a limit in the patients' comprehension of this therapeutic paradigm. There is a compelling imperative to cultivate this strategy, grounded in the prevailing medical landscape.

Views, attitudes, and reported practices of nephrology nurses regarding shared decision-making in end-of-life care

BACKGROUND

End-stage renal disease (ESRD) is the final stage of chronic kidney disease. Yet dialysis is not suitable for all ESRD patients. Moreover, while shared decision-making (SDM) is the preferred model for making medical decisions, little is known about SDM between nephrology nurses and ESRD patients in Israel.

RESEARCH OBJECTIVE

Assessing the views, attitudes, practices, and ethical dilemmas of nephrology nurses in Israel regarding SDM with ESRD patients.

METHODS

Using the descriptive quantitative approach, questionnaires were completed by 444 nephrology nurses in Israel. In addition to conducting descriptive statistics, t-tests for independent samples, f-tests for analysis of variance, and both tests for independence were also performed.

ETHICAL CONSIDERATIONS

The research aims, expected advantages and risks have been explained to respondents before completing the questionnaire to secure informed consent. Anonymity and confidentiality were ensured throughout the study. The study was approved by the Research Ethics Committee at the University of Haifa (Approval # 411/21).

RESULTS

About one-third (30%-36.5%) of nurses reported discussing quality of life issues with ESRD patients, asking about their advance directives/power of attorney, exploring cultural/religious beliefs in end-of-life care, and ask about their preferred place of death. Nurses who convey high levels of patient-centered care (68.9%, p<0.0001), have high end-of-life training (76.2%, p<0.0001), and report cooperating with interdisciplinary teams (63.8%, p = 0.0415), also reported higher SDM practices than others. Nurses who refer less patients to palliative care (70%, p<0.0001) reported higher involvement in SDM compared to other nurses.

CONCLUSIONS

Nephrology nurses in Israel do not tend to implement the SDM model, despite its potential for improving quality of life for ESRD patients and their families and increasing conservative care options. Policy makers and educators in Israel should develop and implement training programs and support in the workplace, to enhance SDM between nephrology nurses and ESRD patients.

Embedding nurse-led supportive care in an outpatient service for patients with Chronic Obstructive Pulmonary Disease

AIM

To describe a small multidisciplinary team's experience of the process of embedding nurse-led supportive care into an existing Chronic Obstructive Pulmonary Disease outpatient service.

DESIGN

Case study methodology METHODS: Data were collected from multiple sources including key documents and semi-structured interviews with healthcare professionals (n = 6) conducted between June and July 2021. A purposive sampling strategy was used. Content analysis was applied to key documents. Interviews were transcribed verbatim and analysed using an inductive approach.

RESULTS

Subcategories under the four-stage process were identified from the data.

ASSESSMENT

evidence of needs of patients with Chronic Obstructive Pulmonary Disease; gaps in care and evidence of other models of supportive care. Planning: setting the supportive care service structure and intention; resources and funding; leadership, specialization and respiratory/palliative care roles.

IMPLEMENTATION

relationships and trust; embedding supportive care and communication.

EVALUATION

benefits and positive outcomes for staff and patients, and, improvements and future considerations for supportive care in the COPD service.

CONCLUSION

A collaboration between respiratory and palliative care services resulted in successfully embedding nurse-led supportive care in a small outpatient service for patients with Chronic Obstructive Pulmonary Disease. Nurses are well placed to lead new models of care that aim to address unmet biopsychosocial-spiritual needs of patients. More research is needed to evaluate nurse-led supportive care in Chronic Obstructive Pulmonary Disease and other chronic illness settings; the effectiveness of nurse-led supportive care from the perspective of patients and caregivers and the impact of nurse-led supportive care on health service usage.

PATIENT OR PUBLIC CONTRIBUTION

The development of the model of care is informed by ongoing discussions with patients with COPD and their caregivers. Data availability statement: Research data are not shared (due to ethical restrictions).

IMPACT

Embedding nurse-led supportive care in an existing Chronic Obstructive Pulmonary Disease outpatient service is achievable. Nurses with clinical expertise can lead innovative models of care that address the unmet biopsychosocial-spiritual needs of patients with conditions such as Chronic Obstructive Pulmonary Disease. Nurse-led supportive care may have utility and relevance in other chronic disease contexts.

Kidney Clinicians' Perceptions of Challenges and Aspirations to Improve End-Of-Life Care Provision

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.

Kidney Supportive Care for Working-Age Adults with Chronic Kidney Disease: A Profile of Characteristics and Symptom Burden

INTRODUCTION

Chronic kidney disease (CKD) affects people across their lifespan. Kidney supportive care (KSC) is typically offered for older people for symptom management, education, and/or advance care planning (ACP). However, younger people may also benefit from KSC. This study sought to explore characteristics of working-age adults with CKD accessing KSC.

METHODS

Using a cross-sectional design, working-age adults (18-64 years) with CKD referred to a KSC service from February 2016 to July 2021 were included. Demographic and clinical data were extracted from patients' hospital records. Self-reported symptoms (Integrated Palliative Care Outcome Scale renal [IPOS-renal]) and health-related quality of life (European quality of life [EQ-5D-5L]) were assessed. Reasons for referral to KSC, kidney replacement therapy (KRT) pathway at referral, and comorbidity calculated using the Charlson Comorbidity Index were also assessed.

RESULTS

One Hundred Fifty-six working-age adults attended the KSC service. Median age was 57 years, with more than half receiving KRT. Weakness (92.2%), poor mobility (83.3%), and pain (82.5%) were the most prevalent and severe symptoms. The majority were referred for symptom management (n = 83, 53.2%) and 27% for ACP (n = 42). The ACP completion rate was low (28.9%). Those on dialysis had significantly higher symptom scores than those not receiving dialysis (p < 0.05).

CONCLUSION

Working-age adults with CKD experience a significant and debilitating symptom burden and need to consider options for treatment. This study provides new understanding about working-age adults with CKD that may help provide the specific support needed to meet their end-of-life care needs.

Treatment decision-making and care among older adults with kidney failure: protocol for a multicentre, prospective observational cohort study with nested substudies and linked qualitative research (the Elderly Advanced CKD Programme)

INTRODUCTION

Shared treatment decision-making and planning of care are fundamental in advanced chronic kidney disease (CKD) management. There are limited data on several key outcomes for the elderly population including survival, quality of life, symptom burden, changes in physical functioning and experienced burden of healthcare. Patients, caregivers and clinicians consequently face significant uncertainty when making life-impacting treatment decisions. The Elderly Advanced CKD Programme includes quantitative and qualitative studies to better address challenges in treatment decision-making and planning of care among this increasingly prevalent elderly cohort.

METHODS AND ANALYSIS

The primary component is OUTcomes of Older patients with Kidney failure (OUTLOOK), a multicentre prospective observational cohort study that will enrol 800 patients ≥75 years with kidney failure (estimated glomerular filtration rate ≤15 mL/min/1.73 m²) across a minimum of six sites in Australia. Patients entered are in the decision-making phase or have recently made a decision on preferred treatment (dialysis, conservative kidney management or undecided). Patients will be prospectively followed until death or a maximum of 4 years, with the primary outcome being survival. Secondary outcomes are receipt of short-term acute dialysis, receipt of long-term maintenance dialysis, changes in biochemistry and end-of-life care characteristics. Data will be used to formulate a risk prediction tool applicable for use in the decision-making phase. The nested substudies Treatment modalities for the InfirM ElderLY with end stage kidney disease (TIMELY) and Caregivers of The InfirM ElderLY with end stage kidney disease (Co-TIMELY) will longitudinally assess quality of life, symptom burden and caregiver burden among 150 patients and 100 caregivers, respectively. CONsumer views of Treatment options for Elderly patieNts with kiDney failure (CONTEND) is an additional qualitative study that will enrol a minimum of 20 patients and 20 caregivers to explore experiences of treatment decision-making and care.

ETHICS AND DISSEMINATION

Ethics approval was obtained through Sydney Local Health District Human Research Ethics Committee (2019/ETH07718, 2020/ETH02226, 2021/ETH01020, 2019/ETH07783). OUTLOOK is approved to have waiver of individual patient consent. TIMELY, Co-TIMELY and CONTEND participants will provide written informed consent. Final results will be disseminated through peer-reviewed journals and presented at scientific meetings.

Burden of kidney failure from atheroembolic disease and association with survival in people receiving dialysis in Australia and New Zealand: a multi-centre registry study

Background

Cardiovascular disease is a leading cause of mortality in kidney failure (KF). Patients with KF from atheroembolic disease are at higher risk of cardiovascular disease than other causes of KF. This study aimed to determine survival on dialysis for patients with KF from atheroembolic disease compared with other causes of KF.

Methods

All adults (≥ 18 years) with KF initiating dialysis as the first kidney replacement therapy between 1 January 1990 and 31 December 2017 according to the Australia and New Zealand Dialysis and Transplant registry were included. Patients were grouped into either: KF from atheroembolic disease and all other causes of KF. Survival outcomes were assessed by the Kaplan-Meier method and Cox regression analysis adjusted for patient-related characteristics.

Results

Among 65,266 people on dialysis during the study period, 334 (0.5%) patients had KF from atheroembolic disease. A decreasing annual incidence of KF from atheroembolic disease was observed from 2008 onwards. Individuals with KF from atheroembolic disease demonstrated worse survival on dialysis compared to those with other causes of KF (HR 1.80, 95% confidence interval [CI] 1.61–2.03). The respective one- and five-year survival rates were 77 and 23% for KF from atheroembolic disease and 88 and 47% for other causes of KF. After adjustment for patient characteristics, KF from atheroembolic disease was not associated with increased patient mortality (adjusted HR 0.93 95% CI 0.82–1.05).

Conclusions

Survival outcomes on dialysis are worse for individuals with KF from atheroembolic disease compared to those with other causes of KF, probably due to patient demographics and higher comorbidity.