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Tsujimoto Y, Aoki T, Shimizu S, Kawarazaki H, Kohatsu K, Nakata T, O'Hare AM, Shibagaki Y, Yamamoto Y, Miyashita J. Perspectives on the optimal timing of advance care planning among Japanese patients undergoing dialysis and clinicians: a cross-sectional study. Clin Exp Nephrol 2024; 28:571-580. [PMID: 38402499 DOI: 10.1007/s10157-024-02458-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 01/03/2024] [Indexed: 02/26/2024]
Abstract
KEY MESSAGES The majority of dialysis patients and clinicians favor early advance care planning in our sample. Yet, there is a disconnect: only 11% of patients discussed future care with their clinicians. Our findings indicate Japanese dialysis patients and clinicians support proactive advance care planning at or before dialysis initiation. BACKGROUND Little is known about the optimal timing of discussions about advance care planning among dialysis patients and clinicians engaged in dialysis care. We aimed to explore the preferred timing for advance care planning and assess actual participation in advance care planning among dialysis patients and their clinicians. METHODS A scenario-based survey on Japanese patients aged ≥65 years on dialysis and clinicians involved in their dialysis care was performed. Participants were asked if they would feel prepared to engage in advance care planning with their clinicians, offering a choice among four hypothetical stages within the illness trajectory, extending from the initiation of dialysis to a later phase characterized by the patient's extreme frailty. RESULTS Overall, 181 patients and 128 clinicians participated in the study. Among these, 131 (72%) patients, and 84 (66%) clinicians indicated that they would prefer to initiate advance care planning around the time of dialysis initiation. Only 20 patients (11%) indicated that they had participated in advance care planning with at least one clinician, including 11 (6%) who indicated that they had discussed their preferences around life-sustaining treatments and 8 (4%) who had discussed their preferences around dialysis continuation. CONCLUSIONS While fewer than 11% of patients undergoing dialysis and their clinicians enrolled in our study had participated in advance care planning, most indicated that they would be comfortable initiating the discussion around the time of dialysis initiation. These findings suggest untapped opportunities to engage patients in advance care planning early in the course of their dialysis.
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Affiliation(s)
- Yasushi Tsujimoto
- Oku Medical Clinic, Osaka, Japan.
- Department of Health Promotion and Human Behavior, Kyoto University Graduate School of Medicine/School of Public Health, Kyoto, Japan.
- Scientific Research Works Peer Support Group, Osaka, Japan.
| | - Takuya Aoki
- Section of Clinical Epidemiology, Department of Community Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
- Division of Clinical Epidemiology, The Jikei University School of Medicine, Tokyo, Japan
| | - Sayaka Shimizu
- Section of Clinical Epidemiology, Department of Community Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Hiroo Kawarazaki
- Department of Nephrology, Inagi Municipal Hospital, Inagi, Japan
- Department of Internal Medicine, Teikyo University Mizonokuchi Hospital, Kanagawa, Japan
| | - Kaori Kohatsu
- Division of Nephrology and Hypertension, St Marianna University School of Medicine, Kanagawa, Japan
| | - Takeshi Nakata
- Department of Endocrinology, Metabolism, Rheumatology and Nephrology, Faculty of Medicine, Oita University, Yufu, Japan
| | - Ann M O'Hare
- Hospital and Specialty Medicine Service, Veteran Affairs Puget Sound Health Care System and University of Washington, Seattle, WA, USA
| | - Yugo Shibagaki
- Division of Nephrology and Hypertension, St Marianna University School of Medicine, Kanagawa, Japan
| | - Yosuke Yamamoto
- Department of Healthcare Epidemiology, Kyoto University Graduate School of Medicine/School of Public Health, Kyoto, Japan
| | - Jun Miyashita
- Department of General Medicine, Shirakawa Satellite for Teaching And Research (STAR), Fukushima Medical University, Fukushima, Japan
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Bursic AE, Schell JO, Ernecoff NC, Bansal AD. Delivery of Active Medical Management without Dialysis through an Embedded Kidney Palliative Care Model. KIDNEY360 2022; 3:1881-1889. [PMID: 36514399 PMCID: PMC9717629 DOI: 10.34067/kid.0001352022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 07/15/2022] [Indexed: 01/12/2023]
Abstract
Background Patients with CKD have high symptom burden, low rates of advance care planning (ACP), and frequently receive care that is not goal concordant. Improved integration of palliative care into nephrology and access to active medical management without dialysis (AMMWD) have the potential to improve outcomes through better symptom management and enhanced shared decision making. Methods We describe the development of a kidney palliative care (KPC) clinic and how palliative care practices are integrated within an academic nephrology clinic. We performed a retrospective electronic health record (EHR) review for patients seen in this clinic between January 2015 and February 2019 to describe key clinical activities and delivery of AMMWD. Results A total of 165 patients were seen in the KPC clinic (139 with CKD and 26 who were already receiving dialysis). Fatigue, mobility issues, and pain were the three most prevalent symptoms (85%, 66%, 58%, respectively). Ninety-one percent of patients had a surrogate decision maker documented in the EHR; 87% of patients had a goals-of-care conversation documented in the EHR. Of the 139 patients with CKD, 67 (48%) chose AMMWD as their disease progressed. Sixty-eight percent (41 of 60) of patients who died during the study were referred to hospice. Conclusions Our findings suggest that the integration of palliative care into nephrology can assist in identification of symptoms, lead to high rates of ACP, and provide a mechanism for patients to choose and receive AMMWD. The percentage of patients choosing AMMWD in our study suggests that increased shared decision making may lower rates of dialysis initiation in the United States. Additional prospective research and registries for assessing the effects of AMMWD have the potential to improve care for people living with CKD.
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Affiliation(s)
- Alexandra E. Bursic
- Renal Electrolyte Division, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jane O. Schell
- Renal Electrolyte Division, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania,Section of Palliative Care and Medical Ethics, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Amar D. Bansal
- Renal Electrolyte Division, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania,Section of Palliative Care and Medical Ethics, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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Yeoh LY, Seow YY, Tan HC. Identifying high-risk hospitalised chronic kidney disease patient using electronic health records for serious illness conversation. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2022; 51:161-169. [PMID: 35373239 DOI: 10.47102/annals-acadmedsg.2021427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
INTRODUCTION This study aimed to identify risk factors that are associated with increased mortality that could prompt a serious illness conversation (SIC) among patients with chronic kidney disease (CKD). METHODS The electronic health records of adult CKD patients admitted between August 2018 and February 2020 were retrospectively reviewed to identify CKD patients with >1 hospitalisation and length of hospital stay ≥4 days. Outcome measures were mortality and the duration of hospitalisation. We also assessed the utility of the Cohen's model to predict 6-month mortality among CKD patients. RESULTS A total of 442 patients (mean age 68.6 years) with median follow-up of 15.3 months were identified. The mean (standard deviation) Charlson Comorbidity Index [CCI] was 6.8±2.0 with 48.4% on chronic dialysis. The overall mortality rate until August 2020 was 36.7%. Mortality was associated with age (hazard ratio [HR] 1.51, 95% confidence interval [CI] 1.29-1.77), CCI≥7 (1.58, 1.08-2.30), lower serum albumin (1.09, 1.06-1.11), readmission within 30-day (1.96, 1.43-2.68) and CKD non-dialysis (1.52, 1.04-2.17). Subgroup analysis of the patients within first 6-month from index admission revealed longer hospitalisation stay for those who died (CKD-non dialysis: 5.5; CKD-dialysis: 8.0 versus 4 days for those survived, P<0.001). The Cohen's model demonstrated reasonable predictive ability to discriminate 6-month mortality (area under the curve 0.81, 95% CI 0.75-0.87). Only 24 (5.4%) CKD patients completed advanced care planning. CONCLUSION CCI, serum albumin and recent hospital readmission could identify CKD patients at higher risk of mortality who could benefit from a serious illness conversation.
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Affiliation(s)
- Lee Ying Yeoh
- Department of General Medicine, Sengkang General Hospital, Singapore
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Saeed F, Murad HF, Wing RE, Li J, Schold JD, Fiscella KA. Outcomes Following In-Hospital Cardiopulmonary Resuscitation in People Receiving Maintenance Dialysis. Kidney Med 2022; 4:100380. [PMID: 35072044 PMCID: PMC8767126 DOI: 10.1016/j.xkme.2021.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Rationale & Objective Previous studies showing poor cardiopulmonary resuscitation (CPR) outcomes in the dialysis population have largely been derived from claims data and are somewhat limited by a lack of detailed characterization of CPR events. We aimed to analyze CPR-related outcomes in individuals receiving maintenance dialysis. Study Design Retrospective chart review. Setting & Participants Using electronic medical records from a single academic health care system, we identified all hospitalized adult patients receiving maintenance dialysis who had undergone in-hospital CPR between 2006 and 2014. Exposure Initial in-hospital CPR. Outcomes Overall survival, predictors of unsuccessful CPR, predictors of death during the same hospitalization among initial survivors, predictors of discharge-to-home status. Analytical Approach We provide descriptive statistics for the study variables and used t tests, χ2 tests, or Fisher exact tests to compare differences between the groups. We built multivariable logistic regression models to examine the CPR-related outcomes. Results A total of 184 patients received in-hospital CPR: 51 (28%) did not survive the initial CPR event, and 77 CPR survivors died (additional 42%) later during the same hospitalization (overall mortality 70%). Only 18 (10%) were discharged home, with the remaining 32 (17%) discharged to a rehabilitation facility or a nursing home. In the multivariable model, the only predictor of unsuccessful CPR was CPR duration (OR, 1.41; 95% CI, 1.24-1.61; P < 0.001). Predictors of death during the same hospitalization after surviving the initial CPR event were CPR duration (OR, 1.15; 95% CI 1.04-1.27; P = 0.007) and older age (OR, 1.64; 95% CI, 1.23-2.2; P < 0.001). Older people also had lower odds of discharge-to-home status (OR, 0.25; 95% CI, 0.11-0.54; P < 0.001). Limitations Retrospective study design, single-center study, no information on functional status. Conclusions Patients receiving maintenance dialysis experience high mortality following in-hospital CPR and only 10% are discharged home. These data may help clinicians provide useful prognostic information while engaging in goals of care conversations.
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Danziger J, Mukamal KJ, Weinhandl E. Associations of Community Water Lead Concentrations with Hemoglobin Concentrations and Erythropoietin-Stimulating Agent Use among Patients with Advanced CKD. J Am Soc Nephrol 2021; 32:2425-2434. [PMID: 34266982 PMCID: PMC8722797 DOI: 10.1681/asn.2020091281] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 03/21/2021] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Although patients with kidney disease may be particularly susceptible to the adverse health effects associated with lead exposure, whether levels of lead found commonly in drinking water are associated with adverse outcomes in patients with ESKD is not known. METHODS To investigate associations of lead in community water systems with hemoglobin concentrations and erythropoietin stimulating agent (ESA) use among incident patients with ESKD, we merged data from the Environmental Protection Agency (EPA) Safe Drinking Water Information System (documenting average 90th percentile lead concentrations in community water systems during 5 years before dialysis initiation, according to city of residence) with patient-level data from the United States Renal Data System. RESULTS Among 597,968 patients initiating dialysis in the United States in 2005 through 2017, those in cities with detectable lead levels in community water had significantly lower pre-ESKD hemoglobin concentrations and more ESA use per 0.01 mg/L increase in 90th percentile water lead. Findings were similar for the 208,912 patients with data from the first month of ESKD therapy, with lower hemoglobin and higher ESA use per 0.01 mg/L higher lead concentration. These associations were observed at lead levels below the EPA threshold (0.015 mg/L) that mandates regulatory action. We also observed environmental inequities, finding significantly higher water lead levels and slower declines over time among Black versus White patients. CONCLUSIONS This first nationwide analysis linking EPA water supply records to patient data shows that even low levels of lead that are commonly encountered in community water systems throughout the United States are associated with lower hemoglobin levels and higher ESA use among patients with advanced kidney disease.
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Affiliation(s)
- John Danziger
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Kenneth J. Mukamal
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Eric Weinhandl
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota,Department of Pharmaceutical Care and Health Systems, University of Minnesota, Minneapolis, Minnesota
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AbuYahya O, Abuhammad S, Hamoudi B, Reuben R, Yaqub M. The do not resuscitate order (DNR) from the perspective of oncology nurses: A study in Saudi Arabia. Int J Clin Pract 2021; 75:e14331. [PMID: 33960067 DOI: 10.1111/ijcp.14331] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 04/13/2021] [Accepted: 05/03/2021] [Indexed: 12/21/2022] Open
Abstract
PURPOSE Issues related to life and death are largely influenced by the culture and religious beliefs of a society. This research aimed to survey a sample of oncology nurses in Saudi Arabia about their attitude towards the do not resuscitate order (DNR). METHOD A cross-sectional design was employed. A survey was sent to 190 nurses in the Comprehensive Cancer Center (CCC) in King Fahad Medical City (KFMC). A total of 157 nurses with a diploma or higher degree agreed to participate in the study. RESULTS Many nurses showed a neutral attitude regarding DNR to cancer patients and/or their families 2.4 ± 0.4. Moreover, the results of the multiple logistic regression tests revealed that all the listed factors are not associated with the attitude towards DNR orders (P > .05). CONCLUSION It is generally believed that nurses the faith and background of nurses from Muslim countries has a profound influence on their attitude towards DNR. However, this was not the picture that was revealed by the results of this study. In this study, all the nurses made it clear that they wanted to know about the autonomy of patients in respect of DNR orders. IMPLICATION TO CLINICAL PRACTICE It is necessary to develop programmes that address the DNR order and respect patient autonomy and rights. Moreover, hospital policies that address the issues of DNR order are required for all end-of-life care.
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Affiliation(s)
- Omar AbuYahya
- Comprehensive Cancer Center (CCC), King Fahad Medical City (KFMC), Riyadh, Saudi Arabia
| | - Sawsan Abuhammad
- Faculty of Nursing, Jordan University of Science and Technology, Irbid, Jordan
| | - Bara Hamoudi
- Comprehensive Cancer Center (CCC), King Fahad Medical City (KFMC), Riyadh, Saudi Arabia
| | - Ranjni Reuben
- Comprehensive Cancer Center (CCC), King Fahad Medical City (KFMC), Riyadh, Saudi Arabia
| | - Muawiyah Yaqub
- Comprehensive Cancer Center (CCC), King Fahad Medical City (KFMC), Riyadh, Saudi Arabia
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Thamcharoen N, Nissaisorakarn P, Cohen RA, Schonberg MA. Serious Illness Conversations in advanced kidney disease: a mixed-methods implementation study. BMJ Support Palliat Care 2021:bmjspcare-2020-002830. [PMID: 33731464 DOI: 10.1136/bmjspcare-2020-002830] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 02/20/2021] [Accepted: 02/24/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Advanced kidney disease is associated with a high risk of morbidity and mortality. Consequently, invasive treatments such as dialysis may not yield survival benefits. Advance care planning has been encouraged. However, whether such discussions are acceptable when done earlier, before end-stage kidney treatment decision-making occurs, is unclear. This pilot study aimed to explore whether use of the Serious Illness Conversation Guide to aid early advance care planning is acceptable, and to evaluate the information gained from these conversations. METHODS Patients with advanced kidney disease (stage 3B and above) and high mortality risk at 2 years were enrolled in this mixed-methods study from an academic nephrology clinic. Semi-structured interviews were conducted using the adapted Serious Illness Conversation Guide. Thematic analysis was used to assess patients' perceptions of the conversation. Participants completed a questionnaire assessing conversation acceptability. RESULTS Twenty-six patients participated, 50% were female. Participants felt that the conversation guide helped them reflect on their prognosis, goals of care and treatment preferences. Most did not feel that the conversation provoked anxiety (23/26, 88%) nor that it decreased hopefulness (24/26, 92%). Some challenges were elicited; patients expressed cognitive dissonance with the kidney disease severity due to lack of symptoms; had difficulty conceptualising their goals of care; and vocalised fear of personal failure without attempting dialysis. CONCLUSIONS Patients in this pilot study found the adapted Serious Illness Conversation Guide acceptable. This guide may be used with patients early in the course of advanced kidney disease to gather information for future advanced care planning.
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Affiliation(s)
- Natanong Thamcharoen
- Cheewabhibaln Palliative Care Center, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
- Nephrology Division, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Pitchaphon Nissaisorakarn
- Nephrology Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Robert A Cohen
- Nephrology Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Mara A Schonberg
- Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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Scherer JS, O'Hare AM. Do-Not-Resuscitate Orders among Patients with ESKD Admitted to the Intensive Care Unit: A Bird's Eye View. J Am Soc Nephrol 2020; 31:2232-2234. [PMID: 32866110 DOI: 10.1681/asn.2020081160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
- Jennifer S Scherer
- Division of Nephrology, New York University Langone Health, New York, New York.,Division of Geriatrics and Palliative Care, New York University Langone Health, New York, New York
| | - Ann M O'Hare
- Department of Medicine, University of Washington, Seattle, Washington .,Hospital and Specialty Medicine Service, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
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