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Dahm MR, Raine SE, Slade D, Chien LJ, Kennard A, Walters G, Spinks T, Talaulikar G. Older patients and dialysis shared decision-making. Insights from an ethnographic discourse analysis of interviews and clinical interactions. PATIENT EDUCATION AND COUNSELING 2024; 122:108124. [PMID: 38232671 DOI: 10.1016/j.pec.2023.108124] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 12/07/2023] [Accepted: 12/17/2023] [Indexed: 01/19/2024]
Abstract
OBJECTIVE To describe and analyse the perspectives and communication practices of kidney clinicians and older patients (aged 60 +) during collaborative education and decision-making about dialysis. METHODS This qualitative study drew on pluralistic data sources and analytical approaches investigating elicited semi-structured interviews (n = 31) with doctors (n = 8), nurses (n = 8) and patients (n = 15), combined with ethnographic observations, written artefacts and audio-recorded naturally-occurring interactions (n = 23, education sessions n = 4; consultations n = 19) in a tertiary Australian kidney outpatient clinic. Data were analysed for themes and linguistic discourse features. RESULTS Five themes were identified across all data sources: 1) lost opportunity in education; 2) persistent disease knowledge gaps; 3) putting up with dialysis; 4) perceived and real involvement in decision-making and 5) complex role of family as decision-making brokers. CONCLUSION As the first study to complement interviews with evidence from naturally-occurring kidney interactions, this study balances the perspectives of how older patients and their clinicians view chronic kidney disease education, with how decision-making about dialysis is reflected in practice. PRACTICE IMPLICATIONS The study provides suggestions for contextualized, multi-perspectives formal and informal training for improving decision-making about dialysis, spanning from indications to boost communication efficiency, to reducing unexplained jargon, incorporating patient navigators and exploring different dialysis modalities.
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Affiliation(s)
- Maria R Dahm
- Institute for Communication in Health Care (ICH), College of Arts and Social Sciences, Australian National University, Canberra, Australia.
| | - Suzanne Eggins Raine
- Institute for Communication in Health Care (ICH), College of Arts and Social Sciences, Australian National University, Canberra, Australia
| | - Diana Slade
- Institute for Communication in Health Care (ICH), College of Arts and Social Sciences, Australian National University, Canberra, Australia
| | - Laura J Chien
- Institute for Communication in Health Care (ICH), College of Arts and Social Sciences, Australian National University, Canberra, Australia
| | - Alice Kennard
- Canberra Hospital Renal Service, Canberra, Australia; College of Health and Medicine, Australian National University, Canberra, Australia
| | - Giles Walters
- Canberra Hospital Renal Service, Canberra, Australia; College of Health and Medicine, Australian National University, Canberra, Australia
| | - Tony Spinks
- Canberra Hospital Renal Service, Canberra, Australia
| | - Girish Talaulikar
- Canberra Hospital Renal Service, Canberra, Australia; College of Health and Medicine, Australian National University, Canberra, Australia
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Canaud B, Stuard S, Laukhuf F, Yan G, Canabal MIG, Lim PS, Kraus MA. Choices in hemodialysis therapies: variants, personalized therapy and application of evidence-based medicine. Clin Kidney J 2021; 14:i45-i58. [PMID: 34987785 PMCID: PMC8711767 DOI: 10.1093/ckj/sfab198] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Indexed: 11/17/2022] Open
Abstract
The extent of removal of the uremic toxins in hemodialysis (HD) therapies depends primarily on the dialysis membrane characteristics and the solute transport mechanisms involved. While designation of ‘flux’ of membranes as well toxicity of compounds that need to be targeted for removal remain unresolved issues, the relative role, efficiency and utilization of solute removal principles to optimize HD treatment are better delineated. Through the combination and intensity of diffusive and convective removal forces, levels of concentrations of a broad spectrum of uremic toxins can be lowered significantly and successfully. Extended clinical experience as well as data from several clinical trials attest to the benefits of convection-based HD treatment modalities. However, the mode of delivery of HD can further enhance the effectiveness of therapies. Other than treatment time, frequency and location that offer clinical benefits and increase patient well-being, treatment- and patient-specific criteria may be tailored for the therapy delivered: electrolytic composition, dialysate buffer and concentration and choice of anticoagulating agent are crucial for dialysis tolerance and efficacy. Evidence-based medicine (EBM) relies on three tenets, i.e. clinical expertise (i.e. doctor), patient-centered values (i.e. patient) and relevant scientific evidence (i.e. science), that have deviated from their initial aim and summarized to scientific evidence, leading to tyranny of randomized controlled trials. One must recognize that practice patterns as shown by Dialysis Outcomes and Practice Patterns Study and personalization of HD care are the main driving force for improving outcomes. Based on a combination of the three pillars of EBM, and particularly on bedside patient–clinician interaction, we summarize what we have learned over the last 6 decades in terms of best practices to improve outcomes in HD patients. Management of initiation of dialysis, vascular access, preservation of kidney function, selection of biocompatible dialysers and use of dialysis fluids of high microbiological purity to restrict inflammation are just some of the approaches where clinical experience is vital in the absence of definitive scientific evidence. Further, HD adequacy needs to be considered as a broad and multitarget approach covering not just the dose of dialysis provided, but meeting individual patient needs (e.g. fluid volume, acid–base, blood pressure, bone disease metabolism control) through regular assessment—and adjustment—of a series of indicators of treatment efficiency. Finally, in whichever way new technologies (i.e. artificial intelligence, connected health) are embraced in the future to improve the delivery of dialysis, the human dimension of the patient–doctor interaction is irreplaceable. Kidney medicine should remain ‘an art’ and will never be just ‘a science’.
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Affiliation(s)
- Bernard Canaud
- Montpellier University, Montpellier, France
- Global Medical Office, FMC Deutschland, Bad Homburg, Germany
| | - Stefano Stuard
- Global Medical Office, Fresenius Medical Care, Bad Homburg, Germany
| | - Frank Laukhuf
- Global Medical Office, Fresenius Medical Care, Bad Homburg, Germany
| | | | | | | | - Michael A Kraus
- Indiana University Medical School, Indianapolis, Indiana, USA
- Global Medical Office, Fresenius Medical Care, Waltham, Massachusetts, USA
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van Eck van der Sluijs A, Vonk S, van Jaarsveld BC, Bonenkamp AA, Abrahams AC. Good practices for dialysis education, treatment, and eHealth: A scoping review. PLoS One 2021; 16:e0255734. [PMID: 34379654 PMCID: PMC8357118 DOI: 10.1371/journal.pone.0255734] [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: 01/30/2021] [Accepted: 07/23/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Recommendations regarding dialysis education and treatment are provided in various (inter)national guidelines, which should ensure that these are applied uniformly in nephrology and dialysis centers. However, there is much practice variation which could be explained by good practices: practices developed by local health care professionals, which are not evidence-based. Because an overview of good practices is lacking, we performed a scoping review to identify and summarize the available good practices for dialysis education, treatment, and eHealth. METHODS Embase, Pubmed, the Cochrane Library, CINAHL databases and Web of Science were searched for relevant articles using all synonyms for the words 'kidney failure', 'dialysis', and 'good practice'. Relevant articles were structured according to the categories dialysis education, dialysis treatment or eHealth, and assessed for content and results. RESULTS Nineteen articles (12 for dialysis education, 3 for dialysis treatment, 4 for eHealth) are identified. The good practices for education endorse the importance of providing complete and objective predialysis education, assisting peritoneal dialysis (PD) patients in adequately performing PD, educating hemodialysis (HD) patients on self-management, and talking with dialysis patients about their prognosis. The good practices for dialysis treatment focus mainly on dialysis access devices and general quality improvement of dialysis care. Finally, eHealth is useful for HD and PD and affects both quality of care and health-related quality of life. CONCLUSION Our scoping review identifies 19 articles describing good practices and their results for dialysis education, dialysis treatment, and eHealth. These good practices could be valuable in addition to guidelines for increasing shared-decision making in predialysis education, using patients' contribution in the implementation of their dialysis treatment, and advanced care planning.
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Affiliation(s)
| | - Sanne Vonk
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Brigit C. van Jaarsveld
- Department of Nephrology, Amsterdam University Medical Centers, Location AMC, Amsterdam, The Netherlands
- Diapriva Dialysis Center, Amsterdam, The Netherlands
| | - Anna A. Bonenkamp
- Department of Nephrology, Amsterdam University Medical Centers, Location AMC, Amsterdam, The Netherlands
| | - Alferso C. Abrahams
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands
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Koch-Weser S, Porteny T, Rifkin DE, Isakova T, Gordon EJ, Rossi A, Baumblatt GL, St Clair Russell J, Damron KC, Wofford S, Agarwal A, Weiner DE, Ladin K. Patient Education for Kidney Failure Treatment: A Mixed-Methods Study. Am J Kidney Dis 2021; 78:690-699. [PMID: 33894282 DOI: 10.1053/j.ajkd.2021.02.334] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 02/12/2021] [Indexed: 01/27/2023]
Abstract
RATIONALE & OBJECTIVE Education programs are needed for people with advanced chronic kidney disease to understand kidney failure treatment options and participate in shared decision-making (SDM). Little is known about the content and accessibility of current education programs or whether they support SDM. STUDY DESIGN Stakeholder-engaged, mixed-methods design incorporating qualitative observations and interviews, and a quantitative content analysis of slide presentations. SETTING & PARTICIPANTS Four sites located in Boston, Chicago, Portland (Maine), and San Diego. ANALYTICAL APPROACH Thematic analysis based on the Ottawa Framework (observations and interviews) and descriptive statistical analysis (slide presentations). RESULTS Data were collected from observations of 9 education sessions, 5 semistructured interviews with educators, and 133 educational slide presentations. Sites offered group classes or one-on-one sessions. Development, quality, and accuracy of educational materials varied widely. Educators emphasized dialysis (often in-center hemodialysis), with little mention of conservative management. Educators reported patients were often referred too late to education sessions and that some patients become overwhelmed if they learn of the implications of kidney failure in a group setting. Commonly, sessions were general and did not provide opportunities for tailored information most supportive of SDM. Few nephrologists were involved in education sessions or aware of the educational content. Content gaps included prognosis, decision support, mental health and cognition, advance care planning, cost, and diet. Slide presentations used did not consistently reflect best practices related to health literacy. LIMITATIONS Findings may not be broadly generalizable. CONCLUSIONS Education sessions focused on kidney failure treatment options do not consistently follow best practices related to health literacy or for supporting SDM. To facilitate SDM, the establishment of expectations for kidney failure treatment options should be clearly defined and integrated into the clinical workflow. Addressing content gaps, health literacy, and communication with nephrologists is necessary to improve patient education in the setting of advanced chronic kidney disease.
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Affiliation(s)
- Susan Koch-Weser
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston
| | - Thalia Porteny
- Departments of Occupational Therapy, Tufts University, Medford, MA
| | - Dena E Rifkin
- Division of Nephrology, Veterans Affairs Healthcare System and University of California, San Diego, San Diego, CA
| | - Tamara Isakova
- Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Chicago, IL
| | - Elisa J Gordon
- Department of Surgery, Division of Transplantation, Center for Health Services and Outcomes Research, and Center for Bioethics and Medical Humanities, Chicago, IL
| | - Ana Rossi
- Piedmont Transplant Institute, Atlanta, GA
| | - Geri Lynn Baumblatt
- Northwestern University Feinberg School of Medicine; Articulations Consulting, Chicago, IL
| | | | | | | | - Arushi Agarwal
- William B. Schwartz Division of Nephrology, Tufts Medical Center, Boston
| | - Daniel E Weiner
- William B. Schwartz Division of Nephrology, Tufts Medical Center, Boston
| | - Keren Ladin
- Departments of Occupational Therapy, Tufts University, Medford, MA; Community Health and Research on Ethics, Aging, and Community Health (REACH Lab), Tufts University, Medford, MA.
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The efficacy of L-carnitine in improving malnutrition in patients on maintenance hemodialysis: a meta-analysis. Biosci Rep 2021; 40:225131. [PMID: 32490516 PMCID: PMC7295622 DOI: 10.1042/bsr20201639] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 05/28/2020] [Accepted: 06/02/2020] [Indexed: 02/07/2023] Open
Abstract
The improvement of malnutrition with levocarnitine in maintenance hemodialysis (MHD) patients is controversial. We performed a meta-analysis to evaluate the efficacy of levocarnitine in improving malnutrition in MHD patients. We performed a literature search for relevant articles related to the treatment of malnutrition by L-carnitine in MHD patients in PubMed, Embase, Web of Science, China National Knowledge Infrastructure, and Wanfang databases. We set the publication dates from 1950 to July 2019. The levels of albumin, prealbumin, total protein, and transferrin before and after treatment were used for assessing malnutrition. Twenty-seven studies were included in the present analysis. The results of the random effects model indicated that L-carnitine treatment improved the albumin level in patients on MHD patients. The pooled standardized mean difference of albumin level was 2.51 (95% confidence interval (CI): 2.13-2.90, P<0.001). The pooled total protein level was 3.83 (95% CI: 2.41-5.24, P = 0.000) and the pooled transferrin level was 0.35 (95% CI: 0.18-0.52, P = 0.000). Significant differences were observed with the total protein and transferrin levels. The results indicated that levocarnitine significantly improved the prealbumin level in patients on MHD. The pooled prealbumin level was 70.86 (95% CI: 42.99-98.73, P = 0.000). No publication bias was detected (P>0.05). The present meta-analysis indicated that L-carnitine can have a favorable effect on malnutrition biomarkers in patients on MHD, including the increase in albumin, total protein, transferrin, and prealbumin levels. The L-carnitine could be an option for treatment of MHD patients.
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Andersen‐Hollekim T, Solbjør M, Kvangarsnes M, Hole T, Landstad BJ. Narratives of patient participation in haemodialysis. J Clin Nurs 2020; 29:2293-2305. [DOI: 10.1111/jocn.15238] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 01/16/2020] [Accepted: 02/07/2020] [Indexed: 02/01/2023]
Affiliation(s)
- Tone Andersen‐Hollekim
- Møre and Romsdal Hospital Trust Ålesund Norway
- Department of Circulation and Medical Imaging Faculty of Medicine and Health Science Norwegian University of Science and Technology Trondheim Norway
| | - Marit Solbjør
- Department of Public Health and Nursing Faculty of Medicine and Health Science Norwegian University of Science and Technology Trondheim Norway
| | - Marit Kvangarsnes
- Møre and Romsdal Hospital Trust Ålesund Norway
- Department of Health Sciences Faculty of Medicine and Health Science Norwegian University of Science and Technology Ålesund Norway
| | - Torstein Hole
- Møre and Romsdal Hospital Trust Ålesund Norway
- Department of Circulation and Medical Imaging Faculty of Medicine and Health Science Norwegian University of Science and Technology Trondheim Norway
| | - Bodil J. Landstad
- Department of Health Sciences Mid Sweden University Östersund Sweden
- Nord‐Trøndelag Hospital Trust Levanger Hospital Levanger Norway
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Abstract
The best treatment option for many patients with kidney failure is a kidney transplant from a living donor. Countries that successfully increase their rate of living kidney donation will decrease their reliance on dialysis, the most expensive and high-risk form of kidney replacement therapy. Outlined here are some barriers that prevent some patients from pursuing living kidney donation and current knowledge on some potential solutions to these barriers. Also described are strategies to promote living kidney donation in a defensible system of practice. Safely increasing the rate of living kidney donation will require better programs and policies to improve the experiences of living donors and their recipients, to safeguard the practice for years to come.
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Affiliation(s)
- Amit X Garg
- Department of Medicine, Epidemiology and Biostatistics, Western University, London, Ontario, Canada
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8
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Jaar BG, Choi MJ. An Introduction to dialysis education: Issues, innovations and impact. Semin Dial 2018; 31:99-101. [PMID: 29509328 DOI: 10.1111/sdi.12680] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Bernard G Jaar
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, MD, USA.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Nephrology Center of Maryland, Baltimore, MD, USA
| | - Michael J Choi
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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