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Hatoum WBA, Sperling D. Shared decision-making in end-of-life care for end-stage renal disease patients: nephrologists' views and attitudes. Isr J Health Policy Res 2024; 13:45. [PMID: 39256820 PMCID: PMC11385125 DOI: 10.1186/s13584-024-00632-w] [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: 07/26/2023] [Accepted: 08/30/2024] [Indexed: 09/12/2024] Open
Abstract
BACKGROUND The term end-stage renal disease (ESRD) refers to the final stage of chronic kidney disease. Not all ESRD patients are suitable for dialysis treatment, which despite its advantages, is not without risks. Shared nephrologist-patient decision-making could be beneficial at this stage, yet little is known about such practices in Israel. This study aimed at examining the practice of shared decision-making (SDM) between nephrologists and ESRD patients in Israel, while exploring related conflicts, ethical dilemmas, and considerations. METHODS The descriptive-quantitative approach applied in this study included a validated questionnaire for nephrologists, based on Emanual and Emanual (1992). The survey, which was distributed via social-media platforms and snowball sampling, was completed by 169 nephrologists. Data analysis included t-tests for independent samples, f-tests for analysis of variance, and t-tests and f-tests for independence. Descriptive analysis examined attitudes towards SDM in end-of-life care for ESRD patients. RESULTS The findings show that the research sample did not include nephrologists who typically act according to the paternalistic decision-making style. Rather, 53% of the respondents were found to act in line with the informative decision-making style, while 47% act according to the interpretive decision-making style. Almost 70% of all respondents reported their discussing quality-of-life with patients; 63.4% provide prognostic assessments; 61.5% inquire about the patient's desired place of death; 58.6% ask about advance directives or power-of-attorney; and 57.4% inquire about cultural and religious beliefs in end-of-life treatment. Additionally, informative nephrologists tend to promote the patients' autonomy over their health (P < 0.001); they are also in favor of conservative treatment, compared to paternalistic and interpretive nephrologists, and use less invasive methods than other nephrologists (P = 0.02). CONCLUSIONS Nephrologists in Israel only partially pursue an SDM model, which has the potential to improve quality-of-care for ESRD patients and their families. SDM programs should be developed and implemented for increasing such practices among nephrologists, thereby expanding the possibilities for providing conservative care at end-of-life.
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Affiliation(s)
- Wassiem Bassam Abu Hatoum
- Faculty of Social Welfare and Health Sciences, Department of Nursing, University of Haifa, 199 Aba Khoushy Ave. Mount Carmel, Haifa, Israel.
- Department of Nephrology and hypertension, Haemek Medical Center, Afula, Israel, Yitshak Rabin Boulevard , 1834111.
| | - Daniel Sperling
- Faculty of Social Welfare and Health Sciences, Department of Nursing, University of Haifa, 199 Aba Khoushy Ave. Mount Carmel, Haifa, Israel
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Kruser JM, Nadig NR, Viglianti EM, Clapp JT, Secunda KE, Halpern SD. Time-Limited Trials for Patients With Critical Illness: A Review of the Literature. Chest 2024; 165:881-891. [PMID: 38101511 PMCID: PMC11243441 DOI: 10.1016/j.chest.2023.12.014] [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: 07/28/2023] [Revised: 11/08/2023] [Accepted: 12/09/2023] [Indexed: 12/17/2023] Open
Abstract
TOPIC IMPORTANCE Since the 1990s, time-limited trials have been described as an approach to navigate uncertain benefits and limits of life-sustaining therapies in patients with critical illness. In this review, we aim to synthesize the evidence on time-limited trials in critical care, establish what is known, and highlight important knowledge gaps. REVIEW FINDINGS We identified 18 empirical studies and 15 ethical analyses about time-limited trials in patients with critical illness. Observational studies suggest time-limited trials are part of current practice in ICUs in the United States, but their use varies according to unit and physician factors. Some ICU physicians are familiar with, endorse, and have participated in time-limited trials, and some older adults appear to favor time-limited trial strategies over indefinite life-sustaining therapy or care immediately focused on comfort. When time-limited trials are used, they are often implemented incompletely and challenged by systematic barriers (eg, continually rotating ICU staff). Predictive modeling studies support prevailing clinical wisdom that prognostic uncertainty decreases over time in the ICU for some patients. One study prospectively comparing usual ICU care with an intervention designed to support time-limited trials yielded promising preliminary results. Ethical analyses describe time-limited trials as a pragmatic approach within the longstanding discussion about withholding and withdrawing life-sustaining therapies. SUMMARY Time-limited trials are endorsed by physicians, align with the priorities of some older adults, and are part of current practice. Substantial efforts are needed to test their impact on patient-centered outcomes, improve their implementation, and maximize their potential benefit.
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Affiliation(s)
- Jacqueline M Kruser
- Division of Allergy, Pulmonary, and Critical Care, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI.
| | - Nandita R Nadig
- Division of Pulmonary and Critical Care, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Elizabeth M Viglianti
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Justin T Clapp
- Department of Anesthesiology & Critical Care, University of Pennsylvania, Philadelphia, PA
| | - Katharine E Secunda
- Division of Pulmonary, Allergy and Critical Care, Department of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Scott D Halpern
- Division of Pulmonary, Allergy and Critical Care, Department of Medicine, University of Pennsylvania, Philadelphia, PA; Palliative and Advanced Illness Research (PAIR) Center, Philadelphia, PA
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3
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Mandel EI, Fox M, Schell JO, Cohen RA. Shared Decision-Making and Patient Communication in Nephrology Practice. ADVANCES IN KIDNEY DISEASE AND HEALTH 2024; 31:5-12. [PMID: 38403394 DOI: 10.1053/j.akdh.2023.12.003] [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: 08/01/2023] [Revised: 11/22/2023] [Accepted: 12/06/2023] [Indexed: 02/27/2024]
Abstract
Shared decision-making (SDM) is the standard of care for patient or surrogates and their clinicians to arrive at a medical decision. Evidence suggests that SDM increases patients' understanding of their illness and satisfaction with their decision-making process. Dialysis patients often report the perception that they were passive participants in the decision to start dialysis, suggesting further opportunities for enhancing the application of SDM in decision-making with patients with kidney disease. The hallmark feature of SDM is sensitive, culturally- and equity-informed communication and effective partnership between patient or surrogate and clinician. In the process, the patient's personal expertise in the realm of their values and priorities is elicited, and the clinician's medical expertise is shared. The integration of this shared expertise then leads to an informed treatment decision. Frameworks such as the Serious Illness Conversation Guide and REMAP are guides for the SDM process, and communication tools and mnemonics can help facilitate SDM conversations. This paper will address SDM in nephrology practice, reviewing underlying supportive evidence, context, and timing for employing SDM in the trajectory of chronic kidney disease and acute kidney injury, special considerations in vulnerable populations to promote health equity, and communication tools and frameworks to facilitate the SDM process. By learning and applying these frameworks and tools, nephrology providers will be able to employ SDM in the management of kidney disease.
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Affiliation(s)
- Ernest I Mandel
- Division of Renal Medicine, Brigham and Women's Hospital, Department of Medicine, Hebrew SeniorLife, Harvard Medical School, Boston, MA.
| | - Monica Fox
- National Kidney Foundation of Illinois, Chicago, IL
| | - Jane O Schell
- Section of Palliative Care and Medical Ethics, Division of General Medicine and Division of Renal-Electrolyte, UPMC Health System, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Robert A Cohen
- Nephrology Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
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4
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Zhang S, Zhu W, Xia J, Zheng Y, Li X, Chen L, Ning X, Qin Y. Urgency for Kidney Palliative Care in Chinese Maintenance Hemodialysis Patients. Kidney Int Rep 2023; 8:2794-2801. [PMID: 38106567 PMCID: PMC10719599 DOI: 10.1016/j.ekir.2023.09.006] [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: 03/29/2023] [Revised: 08/28/2023] [Accepted: 09/04/2023] [Indexed: 12/19/2023] Open
Abstract
Introduction The aim of this study is to understand nephrology medical staff's awareness of, basic knowledge of, practical ability of, and the barriers to palliative kidney care to patients on maintenance hemodialysis (HD) in mainland China. Methods This cross-sectional descriptive study employed convenience sampling of medical staff (physicians and nurses) working in nephrology departments in mainland China. Independent predictors of self-assessment ability for palliative care (PC) were determined using multivariate binary logistic regression. Results Responses were received from medical staff in 28 provinces and 657 questionnaires were analyzed. Among the participants, 53.1% (349/657) were doctors, and only 4.3% claimed to be confident in providing PC to patients on HD. The average score of self-assessing ability for PC was 2.65 ± 1.15 (range 1-5). Among the 580 participants who experienced patient withdrawal from dialysis, only 16.0% reported that their patients had well-planned withdrawal from dialysis. Male (odds ratio [OR] [95% confidence interval [CI], 0.585 [0.34-0.99], P = 0.048), nurse (OR [95% CI], 1.81 [1.01-3.27], P = 0.047), more experience in dealing with deceased cases (OR [95% CI], 1.28 [1.02-1.61], P = 0.034), less experience of medical disputes before/after withdrawal from dialysis (OR [95% CI], 0.62 [0.40-0.98], P = 0.041), and PC training experiences (OR [95% CI], 2.33 [1.86-2.91], P < 0.001) were independently correlated with significant better self-assessing ability for PC. Conclusion This study demonstrates that the nephrology medical staff had a positive attitude but lacked relative knowledge and training in PC. Institutionalized education, training models, practice guidelines for kidney PC, and guidelines for well-planned withdrawal from dialysis according to cultural background are urgently needed in mainland China.
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Affiliation(s)
- Shuo Zhang
- Department of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Wenbo Zhu
- Department of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Jinghua Xia
- Department of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Ying Zheng
- Palliative Care Medicine Center, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Xuemei Li
- Department of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Limeng Chen
- Department of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Xiaohong Ning
- Palliative Care Medicine Center, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
- Department of Geriatrics, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Yan Qin
- Department of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
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5
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Mandel EI, Maloney FL, Pertsch NJ, Gass JD, Sanders JJ, Bernacki RE, Block SD. A Pilot Study of the Serious Illness Conversation Guide in a Dialysis Clinic. Am J Hosp Palliat Care 2023; 40:1106-1113. [PMID: 36708263 DOI: 10.1177/10499091221147303] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Clinician-led conversations about future care priorities occur infrequently with end-stage renal disease (ESRD) patients on dialysis. This was a pilot study of structured serious illness conversations using the Serious Illness Conversation Guide (SICG) in a single dialysis clinic to assess acceptability of the approach and explore conversation themes and potential outcomes among patients with ESRD. Twelve individuals with ESRD on dialysis from a single outpatient dialysis clinic participated in this study. Participants completed a baseline demographics survey, engaged in a clinician-led structured serious illness conversation, and completed an acceptability questionnaire. Conversations were recorded, transcribed and thematically analyzed. The average age of participants was 68.8 years. The conversations averaged 20:53 in length. Ten participants (83%) felt that the conversation was held at the right time in their clinical course and eleven participants (91%) felt that it was worthwhile. Most participants (73%) reported neutral feelings about clinician use of a printed guide. Eleven participants (91%) reported no change in anxiety about their illness following the conversation, and five participants (42%) reported that the conversation increased their hopefulness about future quality of life. Thematic analysis revealed common perspectives on dialysis including that participants view in-center hemodialysis as temporary, compartmentalize their kidney disease, perceive narrowed life experiences and opportunities, and believe dialysis is their only option. This pilot study suggests that clinician-led structured serious illness conversations may be acceptable to patients with ESRD on dialysis. The themes identified can inform future serious illness conversations with dialysis patients.
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Affiliation(s)
- Ernest I Mandel
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Ariadne Labs, Brigham and Women's Hospital and Harvard TH Chan School of Public Health, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Francine L Maloney
- Ariadne Labs, Brigham and Women's Hospital and Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Nathan J Pertsch
- Ariadne Labs, Brigham and Women's Hospital and Harvard TH Chan School of Public Health, Boston, MA, USA
| | | | - Justin J Sanders
- Department of Family Medicine, Faculty of Medicine and Health Sciences, McGill University, Montreal, QC, Canada
| | - Rachelle E Bernacki
- Ariadne Labs, Brigham and Women's Hospital and Harvard TH Chan School of Public Health, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Division of Adult Palliative Care, Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Susan D Block
- Ariadne Labs, Brigham and Women's Hospital and Harvard TH Chan School of Public Health, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
- Departments of Psychiatry and Medicine, Brigham and Women's Hospital, Boston, MA, USA
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Li KC, Brown MA. Conservative Kidney Management: When, Why, and For Whom? Semin Nephrol 2023; 43:151395. [PMID: 37481807 DOI: 10.1016/j.semnephrol.2023.151395] [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] [Indexed: 07/25/2023]
Abstract
Deciding between dialysis and conservative kidney management (CKM) in an elderly or seriously ill person with kidney failure is complex and requires shared decision making. Patients and families look to their nephrologist to provide an individualized recommendation that aligns with patient-centered goals. For a balanced and considered decision to be made, dialysis should not be the default and nephrologists need to be familiar with relevant prognostic information including survival, symptom burden, functional trajectory, and quality of life with dialysis and with CKM. CKM is a holistic, proactive, and multidisciplinary treatment for kidney failure. For some elderly comorbid patients, CKM improves symptom burden and aligns with quality-of-life goals, with modest or no loss of longevity. CKM can be provided by a nephrologist alone but ideally is managed through partnership with a dedicated supportive or palliative care service embedded within the nephrology practice. Treatment decisions are best discussed early in the disease trajectory and occur over many consultations, and nephrologists should be upskilled in communication to better support patients and families in these important conversations. Nephrologists should remain actively involved in their patients' care through to end-of-life care.
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Affiliation(s)
- Kelly Chenlei Li
- Renal Department, St George Hospital, University of New South Wales, Sydney, Australia.
| | - Mark Ashley Brown
- Renal Department, St George Hospital, University of New South Wales, Sydney, Australia
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Hemmat V, Corbett C. Palliative Care for Nephrology Patients in the Intensive Care Unit. Crit Care Nurs Clin North Am 2022; 34:467-479. [DOI: 10.1016/j.cnc.2022.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Palliative Care for Patients with Kidney Disease. J Clin Med 2022; 11:jcm11133923. [PMID: 35807208 PMCID: PMC9267754 DOI: 10.3390/jcm11133923] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 06/27/2022] [Accepted: 07/02/2022] [Indexed: 11/16/2022] Open
Abstract
Interest in palliative care has increased in recent times, particularly in its multidisciplinary approach developed to meet the needs of patients with a life-threatening disease and their families. Although the modern concept of palliative simultaneous care postulates the adoption of these qualitative treatments early on during the life-threatening disease (and potentially just after the diagnosis), palliative care is still reserved for patients at the end of their life in most of the clinical realities, and thus is consequently mistaken for hospice care. Patients with acute or chronic kidney disease (CKD) usually experience poor quality of life and decreased survival expectancy and thus may benefit from palliative care. Palliative care requires close collaboration among multiple health care providers, patients, and their families to share the diagnosis, prognosis, realistic treatment goals, and treatment decisions. Several approaches, such as conservative management, extracorporeal, and peritoneal palliative dialysis, can be attempted to globally meet the needs of patients with kidney disease (e.g., physical, social, psychological, or spiritual needs). Particularly for frail patients, pharmacologic management or peritoneal dialysis may be more appropriate than extracorporeal treatment. Extracorporeal dialysis treatment may be disproportionate in these patients and associated with a high burden of symptoms correlated with this invasive procedure. For those patients undergoing extracorporeal dialysis, individualized goal setting and a broader concept of adequacy should be considered as the foundations of extracorporeal palliative dialysis. Interestingly, little evidence is available on palliative and end of life care for acute kidney injury (AKI) patients. In this review, the main variables influencing medical decision-making about palliative care in patients with kidney disease are described, as well as the different approaches that can fulfill the needs of patients with CKD and AKI.
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Thorsteinsdottir B, Espinoza Suarez NR, Curtis S, Beck AT, Hargraves I, Shaw K, Wong SPY, Hickson LJ, Boehmer KR, Amberg B, Dahlen E, Wirtz C, Albright RC, Kumbamu A, Tilburt JC, Sutton EJ. Older Patients with Advanced Chronic Kidney Disease and Their Perspectives on Prognostic Information: a Qualitative Study. J Gen Intern Med 2022; 37:1031-1037. [PMID: 35083651 PMCID: PMC8971255 DOI: 10.1007/s11606-021-07176-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 09/28/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Prognostic information is key to shared decision-making, particularly in life-limiting illness like advanced chronic kidney disease (CKD). OBJECTIVE To understand the prognostic information preferences expressed by older patients with CKD. DESIGN AND PARTICIPANTS Qualitative study of 28 consecutively enrolled patients over 65 years of age with non-dialysis dependent CKD stages 3b-5, receiving care in a multi-disciplinary CKD clinic. APPROACH Semi-structured telephone or in-person interviews to explore patients' preference for and perceived value of individualized prognostic information. Interviews were analyzed using inductive content analysis. KEY RESULTS We completed interviews with 28 patients (77.7 ± SD 6.8 years, 69% men). Patients varied in their preference for prognostic information and more were interested in their risk of progression to end-stage kidney disease (ESKD) than in life expectancy. Many conflated ESKD risk with risk of death, perceiving a binary choice between dialysis and quick decline and death. Patients expressed that prognostic information would allow them to plan, take care of important business, and think about their treatment options. Patients were accepting of prognostic uncertainty and imagined leveraging it to nurture hope or motivate them to better manage risk factors. They endorsed the desire to receive prognosis of life expectancy even though it may be hard to accept or difficult to talk about but worried it could create helplessness for other patients in their situation. CONCLUSION Most, but not all, patients were interested in prognostic information and could see its value in motivating behavior change and allowing planning. Some patients expressed concern that information on life expectancy might cause depression and hopelessness. Therefore, prognostic information is most appropriate as part of a clinical conversation that fosters shared decision-making and helps patients consider treatment risks, benefits, and burdens in context of their lives.
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Affiliation(s)
- Bjorg Thorsteinsdottir
- Division of Community Internal Medicine, Mayo Clinic, 200 First St SW, Rochester, MN, USA. .,Biomedical Ethics Program, Mayo Clinic, Rochester, MN, USA. .,Knowledge Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA. .,Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.
| | | | - Susan Curtis
- Biomedical Ethics Program, Mayo Clinic, Rochester, MN, USA
| | - Annika T Beck
- Biomedical Ethics Program, Mayo Clinic, Rochester, MN, USA
| | - Ian Hargraves
- Knowledge Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA
| | - Kevin Shaw
- Knowledge Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA
| | - Susan P Y Wong
- University of Washington and VA Puget Sound Health Care System, Seattle, WA, USA
| | - LaTonya J Hickson
- Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.,Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - Kasey R Boehmer
- Knowledge Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA
| | - Brigid Amberg
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - Erin Dahlen
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - Cristina Wirtz
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - Robert C Albright
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - Ashok Kumbamu
- Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Jon C Tilburt
- Biomedical Ethics Program, Mayo Clinic, Rochester, MN, USA.,Divisions of General Internal Medicine All at Mayo Clinic, Rochester, MN, USA
| | - Erica J Sutton
- Biomedical Ethics Program, Mayo Clinic, Rochester, MN, USA
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10
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Khou V, De La Mata NL, Morton RL, Kelly PJ, Webster AC. Cause of death for people with end-stage kidney disease withdrawing from treatment in Australia and New Zealand. Nephrol Dial Transplant 2021; 36:1527-1537. [PMID: 32750144 DOI: 10.1093/ndt/gfaa105] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Withdrawal from renal replacement therapy is common in patients with end-stage kidney disease (ESKD), but end-of-life service planning is challenging without population-specific data. We aimed to describe mortality after treatment withdrawal in Australian and New Zealand ESKD patients and evaluate death-certified causes of death. METHODS We performed a retrospective cohort study on incident patients with ESKD in Australia, 1980-2013, and New Zealand, 1988-2012, from the Australian and New Zealand Dialysis and Transplant registry. We estimated mortality rates (by age, sex, calendar year and country) and summarized withdrawal-related deaths within 12 months of treatment modality change. Certified causes of death were ascertained from data linkage with the Australian National Death Index and New Zealand Mortality Collection database. RESULTS Of 60 823 patients with ESKD, there were 8111 treatment withdrawal deaths and 26 207 other deaths over 381 874 person-years. Withdrawal-related mortality rates were higher in females and older age groups. Rates increased between 1995 and 2013, from 1142 (95% confidence interval 1064-1226) to 2706/100 000 person-years (95% confidence interval 2498-2932), with the greatest increase in 1995-2006. A third of withdrawal deaths occurred within 12 months of treatment modality change. The national death registers reported kidney failure as the underlying cause of death in 20% of withdrawal cases, with other causes including diabetes (21%) and hypertensive disease (7%). Kidney disease was not mentioned for 18% of withdrawal patients. CONCLUSIONS Treatment withdrawal represents 24% of ESKD deaths and has more than doubled in rate since 1988. Population data may supplement, but not replace, clinical data for end-of-life kidney-related service planning.
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Affiliation(s)
- Victor Khou
- Sydney Medical School, University of Sydney, Sydney, Australia.,Sydney School of Public Health, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Nicole L De La Mata
- Sydney School of Public Health, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Rachael L Morton
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, Australia
| | - Patrick J Kelly
- Sydney School of Public Health, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Angela C Webster
- Sydney School of Public Health, Sydney Medical School, University of Sydney, Sydney, Australia.,Centre for Renal and Transplant Research, Westmead Hospital, Sydney, Australia
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11
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Thorsteinsdottir B, Hickson LJ, Giblon R, Pajouhi A, Connell N, Branda M, Vasdev AK, McCoy RG, Zand L, Tangri N, Shah ND. Validation of prognostic indices for short term mortality in an incident dialysis population of older adults >75. PLoS One 2021; 16:e0244081. [PMID: 33471808 PMCID: PMC7816982 DOI: 10.1371/journal.pone.0244081] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 12/03/2020] [Indexed: 11/29/2022] Open
Abstract
Rational and objective Prognosis provides critical knowledge for shared decision making between patients and clinicians. While several prognostic indices for mortality in dialysis patients have been developed, their performance among elderly patients initiating dialysis is unknown, despite great need for reliable prognostication in that context. To assess the performance of 6 previously validated prognostic indices to predict 3 and/or 6 months mortality in a cohort of elderly incident dialysis patients. Study design Validation study of prognostic indices using retrospective cohort data. Indices were compared using the concordance (“c”)-statistic, i.e. area under the receiver operating characteristic curve (ROC). Calibration, sensitivity, specificity, positive and negative predictive values were also calculated. Setting & participants Incident elderly (age ≥75 years; n = 349) dialysis patients at a tertiary referral center. Established predictors Variables for six validated prognostic indices for short term (3 and 6 month) mortality prediction (Foley, NCI, REIN, updated REIN, Thamer, and Wick) were extracted from the electronic medical record. The indices were individually applied as per each index specifications to predict 3- and/or 6-month mortality. Results In our cohort of 349 patients, mean age was 81.5±4.4 years, 66% were male, and median survival was 351 days. The c-statistic for the risk prediction indices ranged from 0.57 to 0.73. Wick ROC 0.73 (0.68, 0.78) and Foley 0.67 (0.61, 0.73) indices performed best. The Foley index was weakly calibrated with poor overall model fit (p <0.01) and overestimated mortality risk, while the Wick index was relatively well-calibrated but underestimated mortality risk. Limitations Small sample size, use of secondary data, need for imputation, homogeneous population. Conclusion Most predictive indices for mortality performed moderately in our incident dialysis population. The Wick and Foley indices were the best performing, but had issues with under and over calibration. More accurate indices for predicting survival in older patients with kidney failure are needed.
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Affiliation(s)
- Bjorg Thorsteinsdottir
- Division of Community Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
- Biomedical Ethics Program, Mayo Clinic, Rochester, Minnesota, United States of America
- Knowledge Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota, United States of America
- Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, United States of America
- * E-mail:
| | - LaTonya J. Hickson
- Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, United States of America
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Rachel Giblon
- Knowledge Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota, United States of America
- Division of Health Care Sciences Research, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Atieh Pajouhi
- Division of Community Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Natalie Connell
- Biomedical Ethics Program, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Megan Branda
- Knowledge Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota, United States of America
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado-Denver Anschutz Medical Campus, Aurora, CO, United States of America
| | - Amrit K. Vasdev
- Division of Community Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Rozalina G. McCoy
- Division of Community Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
- Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Ladan Zand
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Navdeep Tangri
- Department of Medicine, Seven Oaks General Hospital, University of Manitoba, Winnipeg, Canada
- Department of Community Health Sciences, Seven Oaks General Hospital, University of Manitoba, Winnipeg, Canada
| | - Nilay D. Shah
- Knowledge Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota, United States of America
- Division of Health Care Sciences Research, Mayo Clinic, Rochester, Minnesota, United States of America
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12
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Danziger J, Ángel Armengol de la Hoz M, Celi LA, Cohen RA, Mukamal KJ. Use of Do-Not-Resuscitate Orders for Critically Ill Patients with ESKD. J Am Soc Nephrol 2020; 31:2393-2399. [PMID: 32855209 DOI: 10.1681/asn.2020010088] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 06/01/2020] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Despite having high comorbidity rates and shortened life expectancy, patients with ESKD may harbor unrealistically optimistic expectations about their prognoses. Whether this affects resuscitation orders is unknown. METHODS To determine whether do-not-resuscitate (DNR) orders differ among patients with ESKD compared with other critically ill patients, including those with diseases of other major organs, we investigated DNR orders on admission to intensive care units (ICUs) among 106,873 patients in the United States. RESULTS Major organ disease uniformly associated with increased risk of hospital mortality, particularly for cirrhosis (adjusted odds ratio [aOR], 2.67; 95% confidence interval [95% CI], 2.30 to 3.08), and ESKD (aOR, 1.47; 95% CI, 1.31 to 1.65). Compared with critically ill patients without major organ disease, patients with stroke, cancer, heart failure, dementia, chronic obstructive pulmonary disease, and cirrhosis were statistically more likely to have a DNR order on ICU admission; those with ESKD were not. Findings were similar when comparing patients with a single organ disease with those without organ disease. The disconnect between prognosis and DNR use was most notable among Black patients, for whom ESKD (compared with no major organ disease) was associated with a 62% (aOR, 1.62; 95% CI, 1.27 to 2.04) higher odds of hospital mortality, but no appreciable difference in DNR utilization (aOR, 1.06; 95% CI, 0.66 to 1.62). CONCLUSIONS Unlike patients with diseases of other major organs, critically ill patients with ESKD were not more likely to have a DNR order than patients without ESKD. Whether this reflects a greater lack of advance care planning in the nephrology community, as well as a missed opportunity to minimize potentially needless patient suffering, requires further study.
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Affiliation(s)
- John Danziger
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Miguel Ángel Armengol de la Hoz
- Cardiovascular Research Center, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts.,Massachusetts Institute of Technology Critical Data, Laboratory for Computational Physiology, Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, Massachusetts.,Biomedical Engineering and Telemedicine Group, Center for Biomedical Technology, Escuela Tecnica Superior de Ingenieros Telecomunicación, Universidad Politécnica de Madrid, Madrid, Spain
| | - Leo Anthony Celi
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.,Massachusetts Institute of Technology Critical Data, Laboratory for Computational Physiology, Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, Massachusetts
| | - Robert A Cohen
- 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
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13
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Burns RB, Waikar SS, Wachterman MW, Kanjee Z. Management Options for an Older Adult With Advanced Chronic Kidney Disease and Dementia: Grand Rounds Discussion From Beth Israel Deaconess Medical Center. Ann Intern Med 2020; 173:217-225. [PMID: 32745449 PMCID: PMC10585656 DOI: 10.7326/m20-2640] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
About 15% of adults in the United States-37 million persons-have chronic kidney disease (CKD). Chronic kidney disease is divided into 5 groups, ranging from stage 1 to stage 5 CKD, whereas end-stage kidney disease (ESKD) is defined as permanent kidney failure. The treatment options for ESKD are kidney replacement therapy (KRT) and conservative management. The options for KRT include hemodialysis (either in-center or at home), peritoneal dialysis, and kidney transplant. Conservative management, a multidisciplinary model of care for patients with stage 5 CKD who want to avoid dialysis, is guided by patient values, preferences, and goals, with a focus on quality of life and symptom management. In 2015, the Kidney Disease Outcomes Quality Initiative recommended that patients with an estimated glomerular filtration rate below 30 mL/min/1.73 m2 be educated about options for both KRT and conservative management. In 2018, the National Institute for Health and Care Excellence recommended that assessment for KRT or conservative management start at least 1 year before the need for therapy. It also recommended that in choosing a management approach, predicted quality of life, predicted life expectancy, patient preferences, and other patient factors be considered, because little difference in outcomes has been found among options. Here, 2 experts-a nephrologist and a general internist-palliative care physician-reflect on the care of a patient with advanced CKD and mild to moderate dementia. They discuss the management options for patients with advanced CKD, the pros and cons of each method, and how to help a patient choose among the options.
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Affiliation(s)
- Risa B Burns
- Beth Israel Deaconess Medical Center, Boston, Massachusetts (R.B.B., Z.K.)
| | - Sushrut S Waikar
- Boston University Medical Center, Boston, Massachusetts (S.S.W.)
| | | | - Zahir Kanjee
- Beth Israel Deaconess Medical Center, Boston, Massachusetts (R.B.B., Z.K.)
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14
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Fulton AT, Richman K, Azar M, Sanzen K, Devine J, Ferrone C, Tanzer JR, Lally K. A Novel Interprofessional Palliative Care and Geriatrics Curriculum for Nephrology Teams. Am J Hosp Palliat Care 2020; 37:913-917. [DOI: 10.1177/1049909120915462] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Background: The population of older adults with chronic kidney disease (CKD) is increasing and nephrologists need education on the principles of geriatrics and palliative care to effectively care for this population. Objectives: Our objective was to develop and deliver a curriculum to interprofessional clinicians caring for older adults with CKD. The aim of this curriculum would be to improve knowledge of the principles of geriatrics and palliative care. Design: We have previously developed a curriculum on geriatrics and palliative care targeted toward primary care teams. In this project, we used an interdisciplinary steering committee to modify the curriculum for nephrology teams. Setting: This curriculum was delivered in a live grand rounds setting and was recorded and made available via online platform for virtual learning. Participants: The 6-session curriculum was delivered to 611 live and online learners between January 2018 and April 2019, with more than half of the participants (n = 317) completing more than 1 session. Participants came from a variety of disciplines including medicine, nursing, pharmacy, and social work. Results: Participants had a high rate of agreement with the statement that the curriculum met learning objectives, with live participants having stronger agreement. Participants reported that the activity would change their practice behavior by calling palliative care earlier, as well as improving their communication skills. Conclusion: Interprofessional collaboration can result in improved learning around the management of patients with CKD or end-stage kidney disease.
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Affiliation(s)
- Ana Tuya Fulton
- Geriatrics & Palliative Care, Care New England Health System, Providence, RI, USA
- The Warren Alpert School of Medicine, Brown University, Providence, RI, USA
- Integra Community Care Network, LLC, Providence, RI, USA
| | - Katherine Richman
- Geriatrics & Palliative Care, Care New England Health System, Providence, RI, USA
- Providence VA Medical Center, Lifespan, Providence, RI, USA
| | - Maroun Azar
- Geriatrics & Palliative Care, Care New England Health System, Providence, RI, USA
- Brown Medicine, Inc, Providence, RI, USA
| | - Kelley Sanzen
- The Warren Alpert School of Medicine, Brown University, Providence, RI, USA
- Brown Medicine, Inc, Providence, RI, USA
| | | | - Christine Ferrone
- Rhode Island Geriatric Education Center, University of Rhode Island, Kingston, RI, USA
| | - Joshua Ray Tanzer
- Rhode Island Geriatric Education Center, University of Rhode Island, Kingston, RI, USA
| | - Kate Lally
- Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
- Harvard Medical School, Harvard University, Boston, MA, USA
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15
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Ramspek CL, Verberne WR, van Buren M, Dekker FW, Bos WJW, van Diepen M. Predicting mortality risk on dialysis and conservative care: development and internal validation of a prediction tool for older patients with advanced chronic kidney disease. Clin Kidney J 2020; 14:189-196. [PMID: 33564418 PMCID: PMC7857791 DOI: 10.1093/ckj/sfaa021] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 01/24/2020] [Indexed: 02/07/2023] Open
Abstract
Background Conservative care (CC) may be a valid alternative to dialysis for certain older patients with advanced chronic kidney disease (CKD). A model that predicts patient prognosis on both treatment pathways could be of value in shared decision-making. Therefore, the aim is to develop a prediction tool that predicts the mortality risk for the same patient for both dialysis and CC from the time of treatment decision. Methods CKD Stage 4/5 patients aged ≥70 years, treated at a single centre in the Netherlands, were included between 2004 and 2016. Predictors were collected at treatment decision and selected based on literature and an expert panel. Outcome was 2-year mortality. Basic and extended logistic regression models were developed for both the dialysis and CC groups. These models were internally validated with bootstrapping. Model performance was assessed with discrimination and calibration. Results In total, 366 patients were included, of which 126 chose CC. Pre-selected predictors for the basic model were age, estimated glomerular filtration rate, malignancy and cardiovascular disease. Discrimination was moderate, with optimism-corrected C-statistics ranging from 0.675 to 0.750. Calibration plots showed good calibration. Conclusions A prediction tool that predicts 2-year mortality was developed to provide older advanced CKD patients with individualized prognosis estimates for both dialysis and CC. Future studies are needed to test whether our findings hold in other CKD populations. Following external validation, this prediction tool could be used to compare a patient’s prognosis on both dialysis and CC, and help to inform treatment decision-making.
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Affiliation(s)
- Chava L Ramspek
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Wouter R Verberne
- Department of Internal Medicine, St Antonius Hospital, Nieuwegein, The Netherlands.,Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Marjolijn van Buren
- Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands.,Department of Internal Medicine, Haga Hospital, The Hague, The Netherlands
| | - Friedo W Dekker
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Willem Jan W Bos
- Department of Internal Medicine, St Antonius Hospital, Nieuwegein, The Netherlands.,Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Merel van Diepen
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
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16
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End-of-life and palliative care of patients on maintenance hemodialysis treatment: a focus group study. BMC Palliat Care 2019; 18:89. [PMID: 31666038 PMCID: PMC6822338 DOI: 10.1186/s12904-019-0481-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 10/18/2019] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Despite complex illness trajectories and a high symptom burden, palliative care has been sub-optimal for patients with end-stage kidney disease and hemodialysis treatment who have a high rate of hospitalization and intensive care towards end of life. There is a growing awareness that further development of palliative care is required to meet the needs of these patients and their family members. In this process, it is important to explore healthcare professionals' views on provision of care. The aim of this study was therefore to describe nurses' and physicians' perspectives on end-of-life and palliative care of patients treated with maintenance hemodialysis. METHODS Four focus group interviews were conducted with renal nurses (17) and physicians (5) in Sweden. Qualitative content analysis was used to analyze data. RESULTS Participants were committed to giving the best possible care to their patients, but there were challenges and barriers to providing quality palliative care in nephrology settings. Professionals described palliative care as end-of-life care associated with hemodialysis withdrawal or palliative dialysis, but also identified care needs and possibilities that are in line with an earlier integrated palliative approach. This was perceived as complex from an organizational point of view. Participants identified challenges related to coordination of care and different perspectives on care responsibilities that impacted symptom management and patients' quality of life. Communication issues relating to the provision of palliative care were revealed where the hemodialysis setting was regarded as an impediment, and personal and professional experiences, beliefs and knowledge were considered of major importance. CONCLUSIONS Nurses and physicians identified a need for the improvement of both late and earlier palliative care approaches. The results highlighted a requirement for and possibilities of training, counselling and support of health care professionals in the dialysis context. Further, multi-professional palliative care collaborations should be developed to improve the coordination and organization of end-of-life and palliative care of patients and their family members. A climate allowing conversations about advance care planning throughout the illness trajectory may facilitate the gradual integration of palliative care alongside life-prolonging treatment for improved support of patients and families.
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17
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O'Hare AM, Kurella Tamura M, Lavallee DC, Vig EK, Taylor JS, Hall YN, Katz R, Curtis JR, Engelberg RA. Assessment of Self-reported Prognostic Expectations of People Undergoing Dialysis: United States Renal Data System Study of Treatment Preferences (USTATE). JAMA Intern Med 2019; 179:1325-1333. [PMID: 31282920 PMCID: PMC6618699 DOI: 10.1001/jamainternmed.2019.2879] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
IMPORTANCE Prognostic understanding can shape patients' treatment goals and preferences. Patients undergoing dialysis in the United States have limited life expectancy and may receive end-of-life care directed at life extension. Little is known about their prognostic expectations. OBJECTIVE To understand the prognostic expectations of patients undergoing dialysis and how these relate to care planning, goals, and preferences. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional survey study of 996 eligible patients treated with regular dialysis at 31 nonprofit dialysis facilities in 2 metropolitan areas (Seattle, Washington, and Nashville, Tennessee) between April 2015 and October 2018. After a pilot phase, 1434 eligible patients were invited to participate (response rate, 69.5%). To provide a context for interpreting survey participants' prognostic estimates, United States Renal Data System standard analysis files were used to construct a comparison cohort of 307 602 patients undergoing in-center hemodialysis on January 1, 2006, and followed for death through July 31, 2017. Final analyses for this study were conducted between November 2018 and March 2019. EXPOSURES Responses to the question "How long would you guess people your age with similar health conditions usually live?" (<5 years, 5-10 years, >10 years, or not sure). MAIN OUTCOMES AND MEASURES Self-reported (1) documentation of a surrogate decision-maker, (2) documentation of treatment preferences, (3) values around life prolongation, (4) preferences for receipt of cardiopulmonary resuscitation and mechanical ventilation, and (5) desired place of death. RESULTS Of the 996 survey respondents, the mean (SD) age was 62.7 (13.9) years, and 438 (44.0%) were women. Overall, 112 (11.2%) survey respondents selected a prognosis of fewer than 5 years, 150 (15.1%) respondents selected 5 to 10 years, 330 (33.1%) respondents selected more than 10 years, and 404 (40.6%) were not sure. By comparison, 185 427 (60.3%) prevalent US in-center patients undergoing hemodialysis died within 5 years, 58 437 (19.0%) died within 5 to 10 years, and 63 738 (20.7%) lived more than 10 years. In analyses adjusted for participant characteristics, survey respondents with a prognostic expectation of more than 10 years (vs <5 years) were less likely to report documentation of a surrogate decision-maker (adjusted odds ratio [aOR], 0.6; 95% CI, 0.4-0.9) and treatment preferences (aOR, 0.4; 95% CI, 0.2-0.6) and to value comfort over life extension (aOR, 0.1; 95% CI, 0.04-0.3), and were more likely to want cardiopulmonary resuscitation (aOR, 5.3; 95% CI, 3.2-8.7) and mechanical ventilation (aOR, 2.2; 95% CI, 1.2-3.7). The respondents who reported that they were not sure about prognosis had similar associations. CONCLUSIONS AND RELEVANCE Uncertain and overly optimistic prognostic expectations may limit the benefit of advance care planning and contribute to high-intensity end-of-life care in patients undergoing dialysis.
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Affiliation(s)
- Ann M O'Hare
- Department of Medicine, University of Washington, Seattle.,Kidney Research Institute, University of Washington, Seattle.,VA Puget Sound Health Care System, Seattle, Washington
| | - Manjula Kurella Tamura
- Stanford University Medical Center, Palo Alto, California.,Division of Nephrology, Geriatric Research, Education and Clinical Center, VA Palo Alto Health Care System, Palo Alto, California
| | | | - Elizabeth K Vig
- Department of Medicine, University of Washington, Seattle.,VA Puget Sound Health Care System, Seattle, Washington
| | | | - Yoshio N Hall
- Department of Medicine, University of Washington, Seattle.,Kidney Research Institute, University of Washington, Seattle
| | - Ronit Katz
- Department of Medicine, University of Washington, Seattle.,Kidney Research Institute, University of Washington, Seattle
| | - J Randall Curtis
- Department of Medicine, University of Washington, Seattle.,Cambia Palliative Care Center of Excellence, University of Washington, Seattle
| | - Ruth A Engelberg
- Department of Medicine, University of Washington, Seattle.,Cambia Palliative Care Center of Excellence, University of Washington, Seattle
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18
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Bina R, Glasser S, Honovich M, Levinson D, Ferber Y. Nurses perceived preparedness to screen, intervene, and refer women with suspected postpartum depression. Midwifery 2019; 76:132-141. [DOI: 10.1016/j.midw.2019.05.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 05/16/2019] [Accepted: 05/24/2019] [Indexed: 10/26/2022]
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19
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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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20
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Tentori F, Hunt A, Nissenson AR. Palliative dialysis: Addressing the need for alternative dialysis delivery modes. Semin Dial 2019; 32:391-395. [PMID: 31155777 DOI: 10.1111/sdi.12820] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
For some patients with kidney failure, particularly those who have limited life expectancy or severe comorbidities, the "standard" dialysis treatment regimen may be perceived as excessively burdensome and may not align well with the patient's own priorities. For such patients, a palliative approach to the provision of dialysis-whereby treatment is tailored to the needs of the individual so as to optimize quality of life and minimize disease-related symptoms, but limit treatment burden-might offer a way to better align the delivery of care with the life goals of the patient. Here, we discuss the fundamental principles of palliative dialysis: the patients who might most benefit from this approach, treatment strategies and considerations for implementation, as well as potential barriers to its provision.
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Affiliation(s)
- Francesca Tentori
- DaVita Clinical Research, Minneapolis, Minnesota.,DaVita Inc, Denver, Colorado
| | - Abigail Hunt
- DaVita Clinical Research, Minneapolis, Minnesota
| | - Allen R Nissenson
- DaVita Inc, Denver, Colorado.,David Geffen School of Medicine at UCLA, Los Angeles, California
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21
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Saeed F, Sardar MA, Davison SN, Murad H, Duberstein PR, Quill TE. Patients' perspectives on dialysis decision-making and end-of-life care
. Clin Nephrol 2019; 91:294-300. [PMID: 30663974 PMCID: PMC6595398 DOI: 10.5414/cn109608] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 04/10/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Few studies have explored dialysis patients' perspectives on dialysis decision-making and end-of-life-care (EoLC) preferences. We surveyed a racially diverse cohort of maintenance dialysis patients in the Cleveland, OH, USA, metropolitan area. MATERIALS AND METHODS In this cross-sectional study, we administered a 41-item questionnaire to 450 adult chronic dialysis patients. Items assessed patients' knowledge of their kidney disease as well as their attitudes toward chronic kidney disease (CKD) treatment issues and EoLC issues. RESULTS The cohort included 67% Blacks, 27% Caucasians, 2.8% Hispanics, and 2.4% others. The response rate was 94% (423/450). Most patients considered it essential to obtain detailed information about their medical condition (80.6%) and prognosis (78.3%). Nearly 19% of respondents regretted their decision to start dialysis. 41% of patients would prefer treatment(s) aimed at relieving pain rather than prolonging life (30.5%), but a majority would want to be resuscitated (55.3%). Only 8.4% reported having a designated healthcare proxy, and 35.7% reported completing a living will. A significant percentage of patients wished to discuss their quality of life (71%), psychosocial and spiritual concerns (50.4%), and end-of-life issues (38%) with their nephrologist. CONCLUSION Most dialysis patients wish to have more frequent discussions about their disease, prognosis, and EoLC planning. Findings from this study can inform the design of future interventions.
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Affiliation(s)
- Fahad Saeed
- Department of Medicine, Division of Nephrology
- Division of Palliative Care University of Rochester School of Medicine and Dentistry, Rochester
| | | | - Sara N. Davison
- Division of Nephrology & Immunology, University of Alberta, Edmonton, Alberta, Canada, and
| | - Haris Murad
- Section of Nephrology, Yale School of Medicine, New Haven, CT, USA
| | - Paul R. Duberstein
- Division of Palliative Care University of Rochester School of Medicine and Dentistry, Rochester
- Department of Psychiatry, and Department of Family Medicine and Center for Center for Communication and Disparities Research, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Timothy Edward Quill
- Division of Palliative Care University of Rochester School of Medicine and Dentistry, Rochester
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22
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O'Hare AM, Murphy E, Butler CR, Richards CA. Achieving a person-centered approach to dialysis discontinuation: An historical perspective. Semin Dial 2019; 32:396-401. [PMID: 30968459 DOI: 10.1111/sdi.12808] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
In this essay, we describe the evolution of attitudes toward dialysis discontinuation in historical context, beginning with the birth of outpatient dialysis in the 1960s and continuing through the present. From the start, attitudes toward dialysis discontinuation have reflected the clinical context in which dialysis is initiated. In the 1960s and 1970s, dialysis was only available to select patients and concerns about distributive justice weighed heavily. Because there was strong enthusiasm for new technology and dialysis was regarded as a precious resource not to be wasted, stopping treatment had negative moral connotations and was generally viewed as something to be discouraged. More recently, dialysis has become the default treatment for advanced kidney disease in the United States, leading to concerns about overtreatment and whether patients' values, goals, and preferences are sufficiently integrated into treatment decisions. Despite the developments in palliative nephrology over the past 20 years, dialysis discontinuation remains a conundrum for patients, families, and professionals. While contemporary clinical practice guidelines support a person-centered approach toward stopping dialysis treatments, this often occurs in a crisis when all treatment options have been exhausted. Relatively little is known about the impact of dialysis discontinuation on the experiences of patients and families and there is a paucity of high-quality person-centered evidence to guide practice in this area. Clinicians need better insights into decision-making, symptom burden, and other palliative outcomes that patients might expect when they discontinue dialysis treatments to better support decision-making in this area.
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Affiliation(s)
- Ann M O'Hare
- University of Washington, Seattle, Washington.,VA Puget Sound Health Care System, Seattle, Washington
| | | | - Catherine R Butler
- University of Washington, Seattle, Washington.,VA Puget Sound Health Care System, Seattle, Washington
| | - Claire A Richards
- University of Washington, Seattle, Washington.,VA Puget Sound Health Care System, Seattle, Washington
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23
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Nenova Z, Hotchkiss J. Appointment utilization as a trigger for palliative care introduction: A retrospective cohort study. Palliat Med 2019; 33:457-461. [PMID: 30747040 DOI: 10.1177/0269216319828602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Chronic kidney disease palliative care guidelines would benefit from more diverse and objectively defined health status measures. AIM The aim is to identify high-risk patients from administrative data and facilitate timely and uniform palliative care involvement. DESIGN It is a retrospective cohort study. SETTING/PARTICIPANTS In total, 45,368 Veterans, with chronic kidney disease Stage 3, 4, or 5, were monitored for up to 6 years and categorized into three groups, based on whether they died, started dialysis, or avoided both outcomes. RESULTS Patient's appointment utilization was a significant predictor for both outcomes. It separated individuals into low, medium, and high appointment utilizers. Among the low appointment utilizers, the risk of death did not change significantly, while the risk of dialysis increased. Medium appointment utilizers had a stable risk of death and a decreasing risk of dialysis. Significant appointment utilization (above 31 visits during the baseline year) helped high-risk patients avoid both outcomes of interest-death and dialysis. CONCLUSION Our model could justify the creation of a novel palliative care introduction trigger, as patients with medium demand for care may benefit from additional palliative care evaluation. The trigger could facilitate the uniformization of conservative treatment preparations. It could prompt messages to a managing physician when a patient crosses the threshold between low and medium appointment utilization. It may also aid in system-level policy development. Furthermore, our results highlight the benefit of significant appointment utilization among high-risk patients.
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Affiliation(s)
- Zlatana Nenova
- 1 Daniels College of Business, University of Denver, Denver, CO, USA
| | - John Hotchkiss
- 2 Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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Butler CR, Schwarze ML, Katz R, Hailpern SM, Kreuter W, Hall YN, Montez Rath ME, O'Hare AM. Lower Extremity Amputation and Health Care Utilization in the Last Year of Life among Medicare Beneficiaries with ESRD. J Am Soc Nephrol 2019; 30:481-491. [PMID: 30782596 PMCID: PMC6405144 DOI: 10.1681/asn.2018101002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 01/10/2019] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Lower extremity amputation is common among patients with ESRD, and often portends a poor prognosis. However, little is known about end-of-life care among patients with ESRD who undergo amputation. METHODS We conducted a mortality follow-back study of Medicare beneficiaries with ESRD who died in 2002 through 2014 to analyze patterns of lower extremity amputation in the last year of life compared with a parallel cohort of beneficiaries without ESRD. We also examined the relationship between amputation and end-of-life care among the patients with ESRD. RESULTS Overall, 8% of 754,777 beneficiaries with ESRD underwent at least one lower extremity amputation in their last year of life compared with 1% of 958,412 beneficiaries without ESRD. Adjusted analyses of patients with ESRD showed that those who had undergone lower extremity amputation were substantially more likely than those who had not to have been admitted to-and to have had prolonged stays in-acute and subacute care settings during their final year of life. Amputation was also associated with a greater likelihood of dying in the hospital, dialysis discontinuation before death, and less time receiving hospice services. CONCLUSIONS Nearly one in ten patients with ESRD undergoes lower extremity amputation in their last year of life. These patients have prolonged stays in acute and subacute health care settings and appear to have limited access to hospice services. These findings likely signal unmet palliative care needs among seriously ill patients with ESRD who undergo amputation as well as opportunities to improve their care.
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Affiliation(s)
- Catherine R Butler
- Division of Nephrology, Department of Medicine and the Kidney Research Institute, University of Washington, Seattle, Washington;
| | - Margaret L Schwarze
- Division of Vascular Surgery, Department of Surgery, Medical College of Wisconsin, University of Wisconsin, Madison, Wisconsin
| | - Ronit Katz
- Division of Nephrology, Department of Medicine and the Kidney Research Institute, University of Washington, Seattle, Washington
| | - Susan M Hailpern
- Division of Nephrology, Department of Medicine and the Kidney Research Institute, University of Washington, Seattle, Washington
| | - William Kreuter
- Division of Nephrology, Department of Medicine and the Kidney Research Institute, University of Washington, Seattle, Washington
| | - Yoshio N Hall
- Division of Nephrology, Department of Medicine and the Kidney Research Institute, University of Washington, Seattle, Washington
| | - Maria E Montez Rath
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
- Department of Medicine, Stanford University, Stanford, California; and
| | - Ann M O'Hare
- Division of Nephrology, Department of Medicine and the Kidney Research Institute, University of Washington, Seattle, Washington
- Division of Nephrology, Department of Medicine, Veterans Affairs Puget Sound Healthcare System, Seattle, Washington
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25
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Davison SN. Integrating Palliative Care for Patients with Advanced Chronic Kidney Disease: Recent Advances, Remaining Challenges. J Palliat Care 2018. [DOI: 10.1177/082585971102700109] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Sara N. Davison
- Department of Medicine and Institute of Health Economics, University of Alberta, 11–107 Clinical Sciences Building, Edmonton, Alberta, Canada T6G 2G3
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26
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Ladin K, Pandya R, Perrone RD, Meyer KB, Kannam A, Loke R, Oskoui T, Weiner DE, Wong JB. Characterizing Approaches to Dialysis Decision Making with Older Adults: A Qualitative Study of Nephrologists. Clin J Am Soc Nephrol 2018; 13:1188-1196. [PMID: 30049850 PMCID: PMC6086704 DOI: 10.2215/cjn.01740218] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 05/15/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND OBJECTIVES Despite guidelines recommending shared decision making, nephrologists vary significantly in their approaches to discussing conservative management for kidney replacement therapy with older patients. Many older patients do not perceive dialysis initiation as a choice or receive sufficient information about conservative management for reasons incompletely understood. We examined how nephrologists' perceptions of key outcomes and successful versus failed treatment discussions shape their approach and characterized different models of decision making, patient engagement, and conservative management discussion. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Our qualitative study used semistructured interviews with a sample of purposively sampled nephrologists. Interviews were conducted from June 2016 to May 2017 and continued until thematic saturation. Data were analyzed using typological and thematic analyses. RESULTS Among 35 nephrologists from 18 practices, 20% were women, 66% had at least 10 years of nephrology experience, and 80% were from academic medical centers. Four distinct approaches to decision making emerged: paternalist, informative (patient led), interpretive (navigator), and institutionalist. Five themes characterized differences between these approaches, including patient autonomy, engagement and deliberation (disclosing all options, presenting options neutrally, eliciting patient values, and offering explicit treatment recommendation), influence of institutional norms, importance of clinical outcomes (e.g., survival and dialysis initiation), and physician role (educating patients, making decisions, pursuing active therapies, and managing symptoms). Paternalists and institutionalists viewed initiation of dialysis as a measure of success, whereas interpretive and informative nephrologists focused on patient engagement, quality of life, and aligning patient values with treatment. In this sample, only one third of providers presented conservative management to patients, all of whom followed either informative or interpretive approaches. The interpretive model best achieved shared decision making. CONCLUSIONS Differences in nephrologists' perceptions of their role, patient autonomy, and successful versus unsuccessful encounters contribute to variation in decision making for patients with kidney disease.
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Affiliation(s)
- Keren Ladin
- Department of Occupational Therapy and
- Research on Aging, Ethics, and Community Health, Tufts University, Medford, Massachusetts; and
| | - Renuka Pandya
- Research on Aging, Ethics, and Community Health, Tufts University, Medford, Massachusetts; and
| | | | - Klemens B. Meyer
- Department of Medicine, Tufts Medical Center, Boston, Massachusetts
| | - Allison Kannam
- Research on Aging, Ethics, and Community Health, Tufts University, Medford, Massachusetts; and
| | - Rohini Loke
- Research on Aging, Ethics, and Community Health, Tufts University, Medford, Massachusetts; and
| | - Tira Oskoui
- Research on Aging, Ethics, and Community Health, Tufts University, Medford, Massachusetts; and
| | - Daniel E. Weiner
- Department of Medicine, Tufts Medical Center, Boston, Massachusetts
| | - John B. Wong
- Department of Medicine, Tufts Medical Center, Boston, Massachusetts
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27
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Ladin K, Pandya R, Kannam A, Loke R, Oskoui T, Perrone RD, Meyer KB, Weiner DE, Wong JB. Discussing Conservative Management With Older Patients With CKD: An Interview Study of Nephrologists. Am J Kidney Dis 2018; 71:627-635. [PMID: 29396240 PMCID: PMC5916578 DOI: 10.1053/j.ajkd.2017.11.011] [Citation(s) in RCA: 76] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 11/06/2017] [Indexed: 11/11/2022]
Abstract
BACKGROUND Although dialysis may not provide a large survival benefit for older patients with kidney failure, few are informed about conservative management. Barriers and facilitators to discussions about conservative management and nephrologists' decisions to present the option of conservative management may vary within the nephrology provider community. STUDY DESIGN Interview study of nephrologists. SETTING & PARTICIPANTS National sample of US nephrologists sampled based on sex, years in practice, practice type, and region. METHODOLOGY Qualitative semistructured interviews continued until thematic saturation. ANALYTICAL APPROACH Thematic and narrative analysis of recorded and transcribed interviews. RESULTS Among 35 semistructured interviews with nephrologists from 18 practices, 37% described routinely discussing conservative management ("early adopters"). 5 themes and related subthemes reflected issues that influence nephrologists' decisions to discuss conservative management and their approaches to these discussions: struggling to define nephrologists' roles (determining treatment, instilling hope, and improving patient symptoms), circumventing end-of-life conversations (contending with prognostic uncertainty, fearing emotional backlash, jeopardizing relationships, and tailoring information), confronting institutional barriers (time constraints, care coordination, incentives for dialysis, and discomfort with varied conservative management approaches), conservative management as "no care," and moral distress. Nephrologists' approaches to conservative management discussions were shaped by perceptions of their roles and by a common view of conservative management as no care. Their willingness to pursue conservative management was influenced by provider- and institutional-level barriers and experiences with older patients who regretted or had been harmed by dialysis (moral distress). Early adopters routinely discussed conservative management as a way of relieving moral distress, whereas others who were more selective in discussing conservative management experienced greater distress. LIMITATIONS Participants' views are likely most transferable to large academic medical centers, due to oversampling of academic clinicians. CONCLUSIONS Our findings clarify how moral distress serves as a catalyst for conservative management discussion and highlight points of intervention and mechanisms potentially underlying low conservative management use in the United States.
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Affiliation(s)
- Keren Ladin
- Department of Occupational Therapy, Tufts University, Medford, MA; Research on Aging, Ethics, and Community Health, Tufts University, Medford, MA.
| | - Renuka Pandya
- Research on Aging, Ethics, and Community Health, Tufts University, Medford, MA
| | - Allison Kannam
- Research on Aging, Ethics, and Community Health, Tufts University, Medford, MA
| | - Rohini Loke
- Research on Aging, Ethics, and Community Health, Tufts University, Medford, MA
| | - Tira Oskoui
- Research on Aging, Ethics, and Community Health, Tufts University, Medford, MA
| | | | | | | | - John B Wong
- Department of Medicine, Tufts Medical Center, Boston, MA
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28
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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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29
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Scherer JS, Wright R, Blaum CS, Wall SP. Building an Outpatient Kidney Palliative Care Clinical Program. J Pain Symptom Manage 2018; 55:108-116.e2. [PMID: 28803081 DOI: 10.1016/j.jpainsymman.2017.08.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 07/28/2017] [Accepted: 08/03/2017] [Indexed: 11/21/2022]
Abstract
CONTEXT A diagnosis of advanced chronic kidney disease or end-stage renal disease represents a significant life change for patients and families. Individuals often experience high symptom burden, decreased quality of life, increased health care utilization, and end-of-life care discordant with their preferences. Early integration of palliative care with standard nephrology practice in the outpatient setting has the potential to improve quality of life through provision of expert symptom management, emotional support, and facilitation of advance care planning that honors the individual's values and goals. OBJECTIVES This special report describes application of participatory action research methods to develop an outpatient integrated nephrology and palliative care program. METHODS Stakeholder concerns were thematically analyzed to inform translation of a known successful model of outpatient kidney palliative care to a practice in a large urban medical center in the U.S. RESULTS Stakeholder needs and challenges to meeting these needs were identified. We uncovered a shared understanding of the clinical need for palliative care services in nephrology practice but apprehension toward practice change. Action steps to modify the base model were created in response to stakeholder feedback. CONCLUSION The development of a model of care that provides a new approach to clinical practice requires attention to relevant stakeholder concerns. Participatory action research is a useful methodological approach that engages stakeholders and builds partnerships. This creation of shared ownership can facilitate innovation and practice change. We synthesized stakeholder concerns to build a conceptual model for an integrated nephrology and palliative care clinical program.
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Affiliation(s)
- Jennifer S Scherer
- Division of Geriatrics and Palliative Care, Department of Internal Medicine, NYU School of Medicine, New York, New York, USA; Division of Nephrology, Department of Internal Medicine, NYU School of Medicine, New York, New York, USA.
| | - Rebecca Wright
- Community Public Health, Johns Hopkins School of Nursing, Baltimore, Maryland, USA
| | - Caroline S Blaum
- Division of Geriatrics and Palliative Care, Department of Internal Medicine, NYU School of Medicine, New York, New York, USA
| | - Stephen P Wall
- Ronald O. Perelman Department of Emergency Medicine, NYU School of Medicine, New York, New York, USA; Department of Population Health, NYU School of Medicine, New York, New York, USA
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30
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Pena MJ, Stenvinkel P, Kretzler M, Adu D, Agarwal SK, Coresh J, Feldman HI, Fogo AB, Gansevoort RT, Harris DC, Jha V, Liu ZH, Luyckx VA, Massy ZA, Mehta R, Nelson RG, O'Donoghue DJ, Obrador GT, Roberts CJ, Sola L, Sumaili EK, Tatiyanupanwong S, Thomas B, Wiecek A, Parikh CR, Heerspink HJL. Strategies to improve monitoring disease progression, assessing cardiovascular risk, and defining prognostic biomarkers in chronic kidney disease. Kidney Int Suppl (2011) 2017; 7:107-113. [PMID: 30675424 DOI: 10.1016/j.kisu.2017.07.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Chronic kidney disease (CKD) is a major global public health problem with significant gaps in research, care, and policy. In order to mitigate the risks and adverse effects of CKD, the International Society of Nephrology has created a cohesive set of activities to improve the global outcomes of people living with CKD. Improving monitoring of renal disease progression can be done by screening and monitoring albuminuria and estimated glomerular filtration rate in primary care. Consensus on how many times and how often albuminuria and estimated glomerular filtration rate are measured should be defined. Meaningful changes in both renal biomarkers should be determined in order to ascertain what is clinically relevant. Increasing social awareness of CKD and partnering with the technological community may be ways to engage patients. Furthermore, improving the prediction of cardiovascular events in patients with CKD can be achieved by including the renal risk markers albuminuria and estimated glomerular filtration rate in cardiovascular risk algorithms and by encouraging uptake of assessing cardiovascular risk by general practitioners and nephrologists. Finally, examining ways to further validate and implement novel biomarkers for CKD will help mitigate the global problem of CKD. The more frequent use of renal biopsy will facilitate further knowledge into the underlying etiologies of CKD and help put new biomarkers into biological context. Real-world assessments of these biomarkers in existing cohorts is important, as well as obtaining regulatory approval to use these biomarkers in clinical practice. Collaborations among academia, physician and patient groups, industry, payer organizations, and regulatory authorities will help improve the global outcomes of people living with CKD.
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Affiliation(s)
- Michelle J Pena
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Peter Stenvinkel
- Division of Renal Medicine, Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
| | - Matthias Kretzler
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA.,Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, Michigan, USA
| | - Dwomoa Adu
- Department of Medicine and Therapeutics, School of Medicine and Dentistry, University of Ghana, Accra, Ghana
| | - Sanjay Kumar Agarwal
- Department of Nephrology, All India Institute of Medical Sciences, New Delhi, India
| | - Josef Coresh
- Johns Hopkins University Bloomberg School of Public Health, George W. Comstock Center for Public Health Research and Prevention, Baltimore, Maryland, USA.,Johns Hopkins University School of Medicine, Welch Center for Prevention, Epidemiology and Clinical Research, Baltimore, Maryland, USA
| | - Harold I Feldman
- Department of Biostatistics, Epidemiology, and Informatics, and the Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Agnes B Fogo
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Ron T Gansevoort
- Department of Internal Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - David C Harris
- Centre for Transplantation and Renal Research, Westmead Institute for Medical Research, University of Sydney, Sydney, New South Wales, Australia
| | - Vivekanand Jha
- George Institute for Global Health India, New Delhi, India.,University of Oxford, Oxford, UK
| | - Zhi-Hong Liu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Valerie A Luyckx
- Institute of Biomedical Ethics and History of Medicine, University of Zurich, Zurich, Switzerland.,Klinik für Nephrologie, Universitätsspital, Zurich, Switzerland
| | - Ziad A Massy
- Division of Nephrology, Ambroise Paré Hospital, APHP, Boulogne Billancourt/Paris, France.,French National Institute of Health and Medical Research (INSERM) U1018, Team5, Centre for Research in Epidemiology and Population Health (CESP), Paris-Ile-de-France-West, Versailles-Saint-Quentin-en-Yvelines University, Villejuif, France
| | - Ravindra Mehta
- Department of Medicine, University of California San Diego, San Diego, California, USA
| | - Robert G Nelson
- National Institute of Diabetes and Digestive and Kidney Diseases, Phoenix, Arizona, USA
| | - Donal J O'Donoghue
- Department of Renal Medicine, Salford Royal National Health Service (NHS) Foundation Trust, Salford, UK.,Department of Renal Medicine, University of Manchester, Manchester, UK
| | - Gregorio T Obrador
- Faculty of Health Sciences & Universidad Panamericana, Mexico City, Mexico
| | - Charlotte J Roberts
- Standardisation, International Consortium for Health Outcomes Measurement, London, UK
| | - Laura Sola
- Division Epidemiologia, Dirección General de Salud (DIGESA)-Ministerio Salud Publica, Montevideo, Uruguay
| | - Ernest K Sumaili
- Renal Unit, Kinshasa University Hospital, University of Kinshasa, Kinshasa, DR Congo
| | | | - Bernadette Thomas
- Department of Global Health, The University of Washington, Seattle, Washington, USA
| | - Andrzej Wiecek
- Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia, Katowice, Poland
| | - Chirag R Parikh
- Program of Applied Translational Research, Department of Medicine, Yale University, New Haven, Connecticut, USA.,Veterans Affairs Medical Center, West Haven, Connecticut, USA
| | - Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Ceckowski KA, Little DJ, Merighi JR, Browne T, Yuan CM. An end-of-life practice survey among clinical nephrologists associated with a single nephrology fellowship training program. Clin Kidney J 2017; 10:437-442. [PMID: 28852478 PMCID: PMC5570068 DOI: 10.1093/ckj/sfx005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Indexed: 12/25/2022] Open
Abstract
Background Our nephrology fellowship requires specific training in recognition and referral of end-stage renal disease patients likely to benefit from palliative and hospice care. Methods To identify end-of-life (EOL) referral barriers that require greater training emphasis, we performed a cross-sectional, 17-item anonymous online survey (August–October 2015) of 93 nephrologists associated with the program since 1987. Results There was a 61% response rate (57/93 surveys). Ninety-five percent practiced clinical nephrology (54/57). Of these, 51 completed the survey (55% completion rate), and their responses were analyzed. Sixty-four percent were in practice >10 years; 65% resided in the Southern USA. Ninety-two percent felt comfortable discussing EOL care, with no significant difference between those with ≤10 versus >10 years of practice experience (P = 0.28). Thirty-one percent reported referring patients to EOL care ‘somewhat’ or ‘much less often’ than indicated. The most frequent referral barriers were: time-consuming nature of EOL discussions (27%); difficulty in accurately determining prognosis for <6-month survival (35%); patient (63%) and family (71%) unwillingness; and patient (69%) and family (73%) misconceptions. Fifty-seven percent would refer more patients if dialysis or ultrafiltration could be performed in hospice. Some reported that local palliative care resources (12%) and hospice resources (6%) were insufficient. Conclusions The clinical nephrologists surveyed were comfortable with EOL care discussion and referral. Patient, family, prognostic and system barriers exist, and many reported lower than indicated referral rates. Additional efforts, including, but not limited to, EOL training during fellowship, are needed to overcome familial and structural barriers to facilitate nephrologist referral for EOL care.
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Affiliation(s)
- Kevin A Ceckowski
- Department of Medicine, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Dustin J Little
- Department of Medicine, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | | | - Teri Browne
- University of South Carolina, Columbia, SC, USA
| | - Christina M Yuan
- Department of Medicine, Walter Reed National Military Medical Center, Bethesda, MD, USA
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32
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Forzley B, Chiu HHL, Djurdjev O, Carson RC, Hargrove G, Martinusen D, Karim M. A Survey of Canadian Nephrologists Assessing Prognostication in End-Stage Renal Disease. Can J Kidney Health Dis 2017; 4:2054358117725294. [PMID: 28835851 PMCID: PMC5564856 DOI: 10.1177/2054358117725294] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 06/22/2017] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Patients with end-stage renal disease (ESRD) frequently have a relatively poor prognosis with complex care needs that depend on prognosis. While many means of assessing prognosis are available, little is known about how Canadian nephrologists predict prognosis, whether they routinely share prognostic information with their patients, and how this information guides management. OBJECTIVE To guide improvements in the management of patients with ESRD, we aimed to better understand how Canadian nephrologists consider prognosis during routine care. DESIGN AND METHODS A web-based multiple choice survey was designed, and administered to adult nephrologists in Canada through the e-mail list of the Canadian Society of Nephrology. The survey asked the respondents about their routine practice of estimating survival and the perceived importance of prognostic practices and tools in patients with ESRD. Descriptive statistics were used in analyzing the responses. RESULTS Less than half of the respondents indicated they always or often make an explicit attempt to estimate and/or discuss survival with ESRD patients not on dialysis, and 25% reported they do so always or often with patients on dialysis. Survival estimation is most frequently based on clinical gestalt. Respondents endorse a wide range of issues that may be influenced by prognosis, including advance care planning, transplant referral, choice of dialysis access, medication management, and consideration of conservative care. LIMITATIONS This is a Canadian sample of self-reported behavior, which was not validated, and may be less generalizable to non-Canadian health care jurisdictions. CONCLUSIONS In conclusion, prognostication of patients with ESRD is an important issue for nephrologists and impacts management in fairly sophisticated ways. Information sharing on prognosis may be suboptimal.
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Affiliation(s)
- Brian Forzley
- Department of Medicine, Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
- Interior Health Authority, Kelowna, British Columbia, Canada
| | | | | | - Rachel C. Carson
- Department of Medicine, Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
- Island Health Authority, Victoria, British Columbia, Canada
| | - Gaylene Hargrove
- Department of Medicine, Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
- Island Health Authority, Victoria, British Columbia, Canada
| | - Dan Martinusen
- Island Health Authority, Victoria, British Columbia, Canada
- Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Mohamud Karim
- Department of Medicine, Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
- Fraser Health Authority, Surrey, British Columbia, Canada
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33
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Ladin K, Lin N, Hahn E, Zhang G, Koch-Weser S, Weiner DE. Engagement in decision-making and patient satisfaction: a qualitative study of older patients' perceptions of dialysis initiation and modality decisions. Nephrol Dial Transplant 2017; 32:1394-1401. [PMID: 27576590 PMCID: PMC5837335 DOI: 10.1093/ndt/gfw307] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Accepted: 07/01/2016] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Although shared decision-making (SDM) can better align patient preferences with treatment, barriers remain incompletely understood and the impact on patient satisfaction is unknown. METHODS This is a qualitative study with semistructured interviews. A purposive sample of prevalent dialysis patients ≥65 years of age at two facilities in Greater Boston were selected for diversity in time from initiation, race, modality and vintage. A codebook was developed and interrater reliability was 89%. Codes were discussed and organized into themes. RESULTS A total of 31 interviews with 23 in-center hemodialysis patients, 1 home hemodialysis patient and 7 peritoneal dialysis patients were completed. The mean age was 76 ± 9 years. Two dominant themes (with related subthemes) emerged: decision-making experiences and satisfaction, and barriers to SDM. Subthemes included negative versus positive decision-making experiences, struggling for autonomy, being a 'good patient' and lack of choice. In spite of believing that dialysis initiation should be the patient's choice, no patients perceived that they had made a choice. Patients explained that this is due to the perception of imminent death or that the decision to start dialysis belonged to physicians. Clinicians and family frequently overrode patient preferences, with patient autonomy honored mostly to select dialysis modality. Poor decision-making experiences were associated with low treatment satisfaction. CONCLUSIONS Despite recommendations for SDM, many older patients were unaware that dialysis initiation was voluntary, held mistaken beliefs about their prognosis and were not engaged in decision-making, resulting in poor satisfaction. Patients desired greater information, specifically focusing on the acuity of their choice, prognosis and goals of care.
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Affiliation(s)
- Keren Ladin
- Department of Occupational Therapy, Tufts University, Medford, MA, USA
- Research on Aging, Ethics, and Community Health, Tufts University, Medford, MA, USA
| | - Naomi Lin
- Department of Occupational Therapy, Tufts University, Medford, MA, USA
- Research on Aging, Ethics, and Community Health, Tufts University, Medford, MA, USA
| | - Emily Hahn
- Research on Aging, Ethics, and Community Health, Tufts University, Medford, MA, USA
| | - Gregory Zhang
- Research on Aging, Ethics, and Community Health, Tufts University, Medford, MA, USA
| | - Susan Koch-Weser
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, USA
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Abstract
Dialysis-dependent ESRD is a serious illness with high disease burden, morbidity, and mortality. Mortality in the first year on dialysis for individuals over age 75 years old approaches 40%, and even those with better prognoses face multiple hospitalizations and declining functional status. In the last month of life, patients on dialysis over age 65 years old experience higher rates of hospitalization, intensive care unit admission, procedures, and death in hospital than patients with cancer or heart failure, while using hospice services less. This high intensity of care is often inconsistent with the wishes of patients on dialysis but persists due to failure to explore or discuss patient goals, values, and preferences in the context of their serious illness. Fewer than 10% of patients on dialysis report having had a conversation about goals, values, and preferences with their nephrologist, although nearly 90% report wanting this conversation. Many nephrologists shy away from these conversations, because they do not wish to upset their patients, feel that there is too much uncertainty in their ability to predict prognosis, are insecure in their skills at broaching the topic, or have difficulty incorporating the conversations into their clinical workflow. In multiple studies, timely discussions about serious illness care goals, however, have been associated with enhanced goal-consistent care, improved quality of life, and positive family outcomes without an increase in patient distress or anxiety. In this special feature article, we will (1) identify the barriers to serious illness conversations in the dialysis population, (2) review best practices in and specific approaches to conducting serious illness conversations, and (3) offer solutions to overcome barriers as well as practical advice, including specific language and tools, to implement serious illness conversations in the dialysis population.
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Affiliation(s)
- Ernest I. Mandel
- Renal Division, Department of Medicine and
- Ariadne Laboratories, Brigham and Women’s Hospital and Harvard TH Chan School of Public Health, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts; and
| | - Rachelle E. Bernacki
- Ariadne Laboratories, Brigham and Women’s Hospital and Harvard TH Chan School of Public Health, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts; and
- Division of Adult Palliative Care, Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Susan D. Block
- Departments of Psychiatry and Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Ariadne Laboratories, Brigham and Women’s Hospital and Harvard TH Chan School of Public Health, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts; and
- Division of Adult Palliative Care, Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
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Lazenby S, Edwards A, Samuriwo R, Riley S, Murray MA, Carson‐Stevens A. End-of-life care decisions for haemodialysis patients - 'We only tend to have that discussion with them when they start deteriorating'. Health Expect 2017; 20:260-273. [PMID: 26968338 PMCID: PMC5354044 DOI: 10.1111/hex.12454] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/10/2016] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Haemodialysis patients receive very little involvement in their end-of-life care decisions. Issues relating to death and dying are commonly avoided until late in their illness. This study aimed to explore the experiences and perceptions of doctors and nurses in nephrology for involving haemodialysis patients in end-of-life care decisions. METHODS A semi-structured qualitative interview study with 15 doctors and five nurses and thematic analysis of their accounts was conducted. The setting was a large teaching hospital in Wales, UK. RESULTS Prognosis is not routinely discussed with patients, in part due to a difficulty in estimation and the belief that patients do not want or need this information. Advance care planning is rarely carried out, and end-of-life care discussions are seldom initiated prior to patient deterioration. There is variability in end-of-life practices amongst nephrologists; some patients are felt to be withdrawn from dialysis too late. Furthermore, the possibility and implications of withdrawal are not commonly discussed with well patients. Critical barriers hindering better end-of-life care involvement for these patients are outlined. CONCLUSIONS The study provides insights into the complexity of end-of-life conversations and the barriers to achieving better end-of-life communication practices. The results identify opportunities for improving the lives and deaths of haemodialysis patients.
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Affiliation(s)
- Sophia Lazenby
- Primary Care Patient Safety (PISA) Research GroupDivision of Population MedicineSchool of MedicineCardiff UniversityCardiffWalesUK
| | - Adrian Edwards
- Division of Population MedicineSchool of MedicineCardiff UniversityCardiffWalesUK
- Primary and Emergency Care Research (PRIME) Centre WalesCardiff UniversityCardiffWalesUK
| | - Raymond Samuriwo
- School of Healthcare SciencesCardiff UniversityCardiffWalesUK
- Cardiff Institute for Tissue Engineering and RepairCardiff UniversityCardiffWalesUK
- School of HealthcareUniversity of LeedsLeedsUK
| | | | - Mary Ann Murray
- Nursing Palliative Research and Education UnitFaculty of Health SciencesUniversity of OttawaOttawaONCanada
| | - Andrew Carson‐Stevens
- Primary and Emergency Care Research (PRIME) Centre WalesCardiff UniversityCardiffWalesUK
- Department of Family PracticeUniversity of British ColumbiaVancouverBCCanada
- Institute of Healthcare Policy and PracticeUniversity of the West of ScotlandPaisleyScotland
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Moss AH. Integrating Supportive Care Principles Into Dialysis Decision Making: A Primer for Palliative Medicine Providers. J Pain Symptom Manage 2017; 53:656-662.e1. [PMID: 28065700 DOI: 10.1016/j.jpainsymman.2016.10.371] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Revised: 09/22/2016] [Accepted: 09/21/2016] [Indexed: 11/25/2022]
Abstract
Despite advances in predialysis care and dialysis technology, patients with advanced chronic kidney disease and end-stage renal disease continue to experience multiple comorbidities, a high symptom burden, a shortened life expectancy, and substantial physical, emotional, and spiritual suffering. Patients with acute kidney injury and end-stage renal disease, especially if they are older, often undergo prolonged hospitalizations, greater use of intensive medical treatment, and limited survival. Unfortunately, most nephrologists are not trained to conduct shared decision-making conversations to elicit patients' values, preferences, and goals for treatment and address their patients' multifactorial suffering. These patients would benefit from the integration of supportive care principles into their care. This article addresses how supportive care specialists can collaborate with nephrology clinicians to provide patient-centered supportive care and identifies resources to assist them in this endeavor.
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Affiliation(s)
- Alvin H Moss
- Sections of Nephrology and Supportive Care, West Virginia University School of Medicine, Morgantown, West Virginia, USA.
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37
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Luckett T, Spencer L, Morton RL, Pollock CA, Lam L, Silvester W, Sellars M, Detering KM, Butow PN, Tong A, Clayton JM. Advance care planning in chronic kidney disease: A survey of current practice in Australia. Nephrology (Carlton) 2017; 22:139-149. [DOI: 10.1111/nep.12743] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Revised: 02/03/2016] [Accepted: 02/05/2016] [Indexed: 02/05/2023]
Affiliation(s)
- Tim Luckett
- Improving Palliative Care through Clinical Trials (ImPaCCT) New South Wales; New South Wales Australia
- Faculty of Health; University of Technology Sydney (UTS); Sydney New South Wales Australia
| | - Lucy Spencer
- Department of Renal Medicine; Royal North Shore Hospital; Sydney New South Wales Australia
| | - Rachael L Morton
- NHMRC Clinical Trials Centre; The University of Sydney; Sydney New South Wales Australia
| | - Carol A Pollock
- Department of Renal Medicine; Royal North Shore Hospital; Sydney New South Wales Australia
- Sydney Medical School; The University of Sydney; Sydney New South Wales Australia
| | - Lawrence Lam
- Faculty of Health; University of Technology Sydney (UTS); Sydney New South Wales Australia
| | - William Silvester
- Respecting Patient Choices; Austin Health; Melbourne Victoria Australia
| | - Marcus Sellars
- Sydney Medical School; The University of Sydney; Sydney New South Wales Australia
- Respecting Patient Choices; Austin Health; Melbourne Victoria Australia
| | - Karen M Detering
- Respecting Patient Choices; Austin Health; Melbourne Victoria Australia
| | - Phyllis N Butow
- School of Psychology; The University of Sydney; Sydney New South Wales Australia
| | - Allison Tong
- School of Public Health; The University of Sydney; Sydney New South Wales Australia
| | - Josephine M Clayton
- Improving Palliative Care through Clinical Trials (ImPaCCT) New South Wales; New South Wales Australia
- Sydney Medical School; The University of Sydney; Sydney New South Wales Australia
- HammondCare Palliative & Supportive Care Service; Greenwich Hospital; Sydney New South Wales
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38
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Song MK, Ward SE, Lin FC, Hamilton JB, Hanson LC, Hladik GA, Fine JP. Racial Differences in Outcomes of an Advance Care Planning Intervention for Dialysis Patients and Their Surrogates. J Palliat Med 2016; 19:134-42. [PMID: 26840848 DOI: 10.1089/jpm.2015.0232] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND African Americans' beliefs about end-of-life care may differ from those of whites, but racial differences in advance care planning (ACP) outcomes are unknown. OBJECTIVE The aim of this study was to compare the efficacy of an ACP intervention on preparation for end-of-life decision making and post-bereavement outcomes for African Americans and whites on dialysis. METHOD A secondary analysis of data from a randomized trial comparing an ACP intervention (Sharing Patient's Illness Representations to Increase Trust [SPIRIT]) with usual care was conducted. There were 420 participants, 210 patient-surrogate dyads (67.4% African Americans), recruited from 20 dialysis centers in North Carolina. The outcomes of preparation for end-of-life decision making included dyad congruence on goals of care, surrogate decision-making confidence, a composite of the two, and patient decisional conflict assessed at 2, 6, and 12 months post-intervention. Surrogate bereavement outcomes included anxiety, depression, and post-traumatic distress symptoms assessed at 2 weeks, and at 3 and 6 months after the patient's death. RESULTS SPIRIT was superior to usual care in improving dyad congruence (odds ration [OR] = 2.31, p = 0.018), surrogate decision-making confidence (β = 0.18, p = 0.021), and the composite (OR = 2.19, p = 0.028) 2 months post-intervention, but only for African Americans. SPIRIT reduced patient decisional conflict at 6 months for whites and at 12 months for African Americans. Finally, SPIRIT was superior to usual care in reducing surrogates' bereavement depressive symptoms for African Americans but not for whites (β = -3.49, p = 0.003). CONCLUSION SPIRIT was effective in improving preparation for end-of-life decision-making and post-bereavement outcomes in African Americans.
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Affiliation(s)
- Mi-Kyung Song
- 1 Nell Hodgson School of Nursing, Emory University , Atlanta, Georgia
| | - Sandra E Ward
- 2 School of Nursing, University of Wisconsin-Madison , Madison, Wisconsin
| | - Feng-Chang Lin
- 3 School of Public Health, Department of Biostatistics, University of North Carolina at Chapel Hill , Chapel Hill, North Carolina
| | - Jill B Hamilton
- 4 School of Nursing, Johns Hopkins University , Baltimore, Maryland
| | - Laura C Hanson
- 5 School of Medicine, University of North Carolina at Chapel Hill , Chapel Hill, North Carolina
| | | | - Jason P Fine
- 3 School of Public Health, Department of Biostatistics, University of North Carolina at Chapel Hill , Chapel Hill, North Carolina
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Morton RL, Webster AC, McGeechan K, Howard K, Murtagh FE, Gray NA, Kerr PG, Germain MJ, Snelling P. Conservative Management and End-of-Life Care in an Australian Cohort with ESRD. Clin J Am Soc Nephrol 2016; 11:2195-2203. [PMID: 27697783 PMCID: PMC5142079 DOI: 10.2215/cjn.11861115] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Accepted: 07/28/2016] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES We aimed to determine the proportion of patients who switched to dialysis after confirmed plans for conservative care and compare survival and end-of-life care among patients choosing conservative care with those initiating RRT. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS A cohort study of 721 patients on incident dialysis, patients receiving transplants, and conservatively managed patients from 66 Australian renal units entered into the Patient Information about Options for Treatment Study from July 1 to September 30, 2009 were followed for 3 years. A two-sided binomial test assessed the proportion of patients who switched from conservative care to RRT. Cox regression, stratified by center and adjusted for patient and treatment characteristics, estimated factors associated with 3-year survival. RESULTS In total, 102 of 721 patients planned for conservative care, and median age was 80 years old. Of these, 8% (95% confidence interval, 3% to 13%), switched to dialysis, predominantly for symptom management. Of 94 patients remaining on a conservative pathway, 18% were alive at 3 years. Of the total 721 patients, 247 (34%) died by study end. In multivariable analysis, factors associated with all-cause mortality included older age (hazard ratio, 1.55; 95% confidence interval, 1.36 to 1.77), baseline serum albumin <3.0 versus 3.7-5.4 g/dl (hazard ratio, 4.31; 95% confidence interval, 2.72 to 6.81), and management with conservative care compared with RRT (hazard ratio, 2.18; 95% confidence interval, 1.39 to 3.40). Of 247 deaths, patients managed with RRT were less likely to receive specialist palliative care (26% versus 57%; P<0.001), more likely to die in the hospital (66% versus 42%; P<0.001) than home or hospice, and more likely to receive palliative care only within the last week of life (42% versus 15%; P<0.001) than those managed conservatively. CONCLUSIONS Survival after 3 years of conservative management is common, with relatively few patients switching to dialysis. Specialist palliative care services are used more frequently and at an earlier time point for conservatively managed patients, a practice associated with better symptom management and quality of life.
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Affiliation(s)
- Rachael L. Morton
- National Health and Medical Research Council Clinical Trials Centre, Sydney Medical School and
| | - Angela C. Webster
- Sydney School of Public Health, The University of Sydney, Camperdown, New South Wales, Australia
| | - Kevin McGeechan
- Sydney School of Public Health, The University of Sydney, Camperdown, New South Wales, Australia
| | - Kirsten Howard
- Sydney School of Public Health, The University of Sydney, Camperdown, New South Wales, Australia
| | - Fliss E.M. Murtagh
- Cicely Saunders Institute, King’s College London, Denmark Hill, United Kingdom
| | - Nicholas A. Gray
- Sunshine Coast Clinical School, The University of Queensland and Renal Unit, Nambour General Hospital, Nambour, Australia
| | - Peter G. Kerr
- Department of Nephrology, Monash Medical Centre, Clayton, Australia
| | - Michael J. Germain
- Department of Medicine, Division of Nephology, Baystate Medical Center, Springfield, Massachusetts; and
| | - Paul Snelling
- Department of Renal Medicine Royal Prince Alfred Hospital, Camperdown, Australia
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Couchoud C, Hemmelgarn B, Kotanko P, Germain MJ, Moranne O, Davison SN. Supportive Care: Time to Change Our Prognostic Tools and Their Use in CKD. Clin J Am Soc Nephrol 2016; 11:1892-1901. [PMID: 27510452 PMCID: PMC5053799 DOI: 10.2215/cjn.12631115] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
In using a patient-centered approach, neither a clinician nor a prognostic score can predict with absolute certainty how well a patient will do or how long he will live; however, validated prognostic scores may improve accuracy of prognostic estimates, thereby enhancing the ability of the clinicians to appreciate the individual burden of disease and the prognosis of their patients and inform them accordingly. They may also facilitate nephrologist's recommendation of dialysis services to those who may benefit and proposal of alternative care pathways that might better respect patients' values and goals to those who are unlikely to benefit. The purpose of this article is to discuss the use as well as the limits and deficiencies of currently available prognostic tools. It will describe new predictors that could be integrated in future scores and the role of patients' priorities in development of new scores. Delivering patient-centered care requires an understanding of patients' priorities that are important and relevant to them. Because of limits of available scores, the contribution of new prognostic tools with specific markers of the trajectories for patients with CKD and patients' health reports should be evaluated in relation to their transportability to different clinical and cultural contexts and their potential for integration into the decision-making processes. The benefit of their use then needs to be quantified in clinical practice by outcome studies including health-related quality of life, patient and caregiver satisfaction, or utility for improving clinical management pathways and tailoring individualized patient-centered strategies of care. Future research also needs to incorporate qualitative methods involving patients and their caregivers to better understand the barriers and facilitators to use of these tools in the clinical setting. Information given to patients should be supported by a more realistic approach to what dialysis is likely to entail for the individual patient in terms of likely quality and quantity of life according to the patient's values and goals and not just the possibility of life prolongation.
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Affiliation(s)
- Cécile Couchoud
- French End-Stage Renal Disease Registry Renal Epidemiology and Information Network, Agence de la Biomédecine, St. Denis La Plaine, France
| | - Brenda Hemmelgarn
- Departments of Community Health Sciences and
- Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Peter Kotanko
- Renal Research Institute, New York, New York
- Nephrology Department, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Michael J. Germain
- Division of Nephrology, Baystate Medical Center, Tufts University School of Medicine, Springfield, Massachusetts
| | - Olivier Moranne
- Service de Néphrologie-Suppélance rénale, Hôpital Caremeau, Centre Hospitalo-universitaire Nîmes, Nîmes France
- Equipe d'accueil 2415, Biostatistique, Epidémiologie et Santé Publique, Institut Universitaire de Recherche Clinique, Université de Montpellier, Montpellier, France; and
| | - Sara N. Davison
- Division of Nephrology and Immunology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
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Courtright KR, Madden V, Gabler NB, Cooney E, Kim J, Herbst N, Burgoon L, Whealdon J, Dember LM, Halpern SD. A Randomized Trial of Expanding Choice Sets to Motivate Advance Directive Completion. Med Decis Making 2016; 37:544-554. [PMID: 27510741 DOI: 10.1177/0272989x16663709] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Evidence suggests that advance directives may improve end-of-life care among seriously ill patients, but improving completion rates remains a challenge. OBJECTIVE This study tested the influence of increasing the number of options for completing an advance directive among seriously ill patients. METHODOLOGY Outpatients ( N = 316) receiving hemodialysis across 15 dialysis centers in the Philadelphia region between July 2014 and July 2015 were randomized to receive either the option to complete a brief advance directive form or expanded options including a brief, expanded, or comprehensive form. Patients in both groups could decline to complete an advance directive or take their selected version home. The primary outcome was a returned, completed advance directive. Secondary outcomes included whether patients wanted to complete an advance directive, decision satisfaction, quality of life at 3 months, and patient factors associated with advance directive completion. RESULTS Although offering more advance directive options was not significantly associated with increased rates of completion (13.1% in the standard group v. 12.2% in the expanded group, P = 0.80), it did significantly increase the proportion of patients who wanted to complete an advance directive and took one home (71.9% in standard v. 85.3% in expanded, P = 0.004). There was no difference in satisfaction ( P = 0.65) or change in quality of life between groups ( P = 0.63). A higher baseline quality of life was independently associated with advance directive completion ( P = 0.006). CONCLUSIONS AND RELEVANCE These results suggest that although an expanded choice set may initially nudge patients toward completing advance directives without restricting choice, increasing actual completion requires additional interventions that overcome downstream barriers.
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Affiliation(s)
- Katherine R Courtright
- Pulmonary, Allergy and Critical Care Division, University of Pennsylvania, Philadelphia, PA (KRC, SDH).,Fostering Improvement in End-of-Life Decision Science Program, University of Pennsylvania, Philadelphia, PA (KRC, VM, NBG, EC, JK, LB, SDH)
| | - Vanessa Madden
- Fostering Improvement in End-of-Life Decision Science Program, University of Pennsylvania, Philadelphia, PA (KRC, VM, NBG, EC, JK, LB, SDH).,Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA (VM, NBG, EC, SDH)
| | - Nicole B Gabler
- Fostering Improvement in End-of-Life Decision Science Program, University of Pennsylvania, Philadelphia, PA (KRC, VM, NBG, EC, JK, LB, SDH).,Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA (VM, NBG, EC, SDH)
| | - Elizabeth Cooney
- Fostering Improvement in End-of-Life Decision Science Program, University of Pennsylvania, Philadelphia, PA (KRC, VM, NBG, EC, JK, LB, SDH).,Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA (VM, NBG, EC, SDH)
| | - Jennifer Kim
- Fostering Improvement in End-of-Life Decision Science Program, University of Pennsylvania, Philadelphia, PA (KRC, VM, NBG, EC, JK, LB, SDH)
| | - Nicole Herbst
- Department of Medicine, Boston University Medical Center, Boston, MA (NH)
| | - Lauren Burgoon
- Fostering Improvement in End-of-Life Decision Science Program, University of Pennsylvania, Philadelphia, PA (KRC, VM, NBG, EC, JK, LB, SDH)
| | - Jennifer Whealdon
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA (JW, SDH)
| | - Laura M Dember
- Renal-Electrolyte and Hypertension Division, University of Pennsylvania, Philadelphia, PA (LMD)
| | - Scott D Halpern
- Pulmonary, Allergy and Critical Care Division, University of Pennsylvania, Philadelphia, PA (KRC, SDH).,Fostering Improvement in End-of-Life Decision Science Program, University of Pennsylvania, Philadelphia, PA (KRC, VM, NBG, EC, JK, LB, SDH).,Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA (VM, NBG, EC, SDH).,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA (JW, SDH)
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Fung E, Slesnick N, Kurella Tamura M, Schiller B. A survey of views and practice patterns of dialysis medical directors toward end-of-life decision making for patients with end-stage renal disease. Palliat Med 2016; 30:653-60. [PMID: 26814215 PMCID: PMC4930395 DOI: 10.1177/0269216315625856] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Patients with end-stage renal disease report infrequent end-of-life discussions, and nephrology trainees report feeling unprepared for end-of-life decision making, but the views of dialysis medical directors have not been studied. AIM Our objective is to understand dialysis medical directors' views and practice patterns on end-of-life decision making for patients with ESRD. DESIGN We administered questionnaires to dialysis medical directors during medical director meetings of three different dialysis organizations in 2013. Survey questions corresponded to recommendations from the Renal Physicians Association clinical practice guidelines on initiation and withdrawal of dialysis. SETTING/PARTICIPANTS There were 121 medical director respondents from 28 states. RESULTS The majority of respondents felt "very prepared" (66%) or "somewhat prepared" (29%) to participate in end-of-life decisions and most (80%) endorsed a model of shared decision making. If asked to do so, 70% of the respondents provided prognostic information "often" or "nearly always." For patients with a poor prognosis, 36% of respondents would offer a time-limited trial of dialysis "often" or "nearly always", while 56% of respondents would suggest withdrawal from dialysis "often" or "nearly always" for those with a poor prognosis currently receiving dialysis therapy. Patient resistance and fear of taking away hope were the most commonly cited barriers to end-of-life discussions. CONCLUSION Views and reported practice patterns of medical directors are consistent with clinical practice guidelines for end-of-life decision making for patients with end-stage renal disease but inconsistent with patient perceptions.
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Affiliation(s)
- Enrica Fung
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA, USA
| | | | - Manjula Kurella Tamura
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA, USA VA Palo Alto Geriatric Research and Education Clinical Center, Palo Alto, CA, USA
| | - Brigitte Schiller
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA, USA Satellite Healthcare, San Jose, CA, USA
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43
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Green JA, Boulware LE. Patient Education and Support During CKD Transitions: When the Possible Becomes Probable. Adv Chronic Kidney Dis 2016; 23:231-9. [PMID: 27324676 DOI: 10.1053/j.ackd.2016.04.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Revised: 03/22/2016] [Accepted: 04/12/2016] [Indexed: 11/11/2022]
Abstract
Patients transitioning from kidney disease to kidney failure require comprehensive patient-centered education and support. Efforts to prepare patients for this transition often fail to meet patients' needs due to uncertainty about which patients will progress to kidney failure, nonindividualized patient education programs, inadequate psychosocial support, or lack of assistance to guide patients through complex treatment plans. Resources are available to help overcome barriers to providing optimal care during this time, including prognostic tools, educational lesson plans, decision aids, communication skills training, peer support, and patient navigation programs. New models are being studied to comprehensively address patients' needs and improve the lives of kidney patients during this high-risk time.
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44
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Sexton DJ, Lowney AC, O'Seaghdha CM, Murphy M, O'Brien T, Casserly LF, McQuillan R, Plant WD, Eustace JA, Kinsella SM, Conlon PJ. Do patient-reported measures of symptoms and health status predict mortality in hemodialysis? An assessment of POS-S Renal and EQ-5D. Hemodial Int 2016; 20:618-630. [DOI: 10.1111/hdi.12415] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Donal J. Sexton
- Health Research Board of Ireland Clinical Research Facility; National University of Ireland Galway; Galway Ireland
| | - Aoife C. Lowney
- Department of Palliative Medicine; Marymount University Hospital & Hospice; Cork Ireland
| | | | - Marie Murphy
- Department of Palliative Medicine; Marymount University Hospital & Hospice; Cork Ireland
| | - Tony O'Brien
- Department of Palliative Medicine; Marymount University Hospital & Hospice; Cork Ireland
| | - Liam F. Casserly
- Department of Nephrology; University Hospital Limerick; Limerick Ireland
| | - Regina McQuillan
- Department of Palliative Medicine; Beaumont Hospital; Dublin Ireland
| | - William D. Plant
- Department of Renal Medicine; Cork University Hospital; Cork Ireland
| | - Joseph A. Eustace
- Department of Renal Medicine; Cork University Hospital; Cork Ireland
- Health Research Board of Ireland Clinical Research Facility; University College Cork; Cork Ireland
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Parvez S, Abdel-Kader K, Pankratz VS, Song MK, Unruh M. Provider Knowledge, Attitudes, and Practices Surrounding Conservative Management for Patients with Advanced CKD. Clin J Am Soc Nephrol 2016; 11:812-820. [PMID: 27084874 PMCID: PMC4858478 DOI: 10.2215/cjn.07180715] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Accepted: 02/06/2016] [Indexed: 01/23/2023]
Abstract
BACKGROUND AND OBJECTIVES Despite the potential benefits of conservative management, providers rarely discuss it as a viable treatment option for patients with advanced CKD. This survey was to describe the knowledge, attitudes, and practices of nephrologists and primary care providers regarding conservative management for patients with advanced CKD in the United States. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We developed a questionnaire on the basis of a literature review to include items assessing knowledge, attitudes, and self-reported practices of conservative management for patients with advanced CKD. Potential participants were identified using the American Medical Association Physician Masterfile. We then conducted a web-based survey between April and May of 2015. RESULTS In total, 431 (67.6% nephrologists and 32.4% primary care providers) providers completed the survey for a crude response rate of 2.7%. The respondents were generally white, men, and in their 30s and 40s. Most primary care provider (83.5%) and nephrology (78.2%) respondents reported that they were likely to discuss conservative management with their older patients with advanced CKD. Self-reported number of patients managed conservatively was >11 patients for 30.6% of nephrologists and 49.2% of primary care providers. Nephrologists were more likely to endorse difficulty determining whether a patient with CKD would benefit from conservative management (52.8% versus 36.2% of primary care providers), whereas primary care providers were more likely to endorse limited information on effectiveness (49.6% versus 24.5% of nephrologists) and difficulty determining eligibility for conservative management (42.5% versus 14.3% of nephrologists). There were also significant differences in knowledge between the groups, with primary care providers reporting more uncertainty about relative survival rates with conservative management compared with different patient groups. CONCLUSIONS Both nephrologists and primary care providers reported being comfortable with discussing conservative management with their patients. However, both provider groups identified lack of United States data on outcomes of conservative management and characteristics of patients who would benefit from conservative management as barriers to recommending conservative management in practice.
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Affiliation(s)
- Sanah Parvez
- Division of Nephrology, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Khaled Abdel-Kader
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee
- Vanderbilt Center for Kidney Disease, Nashville, Tennessee; and
| | - V. Shane Pankratz
- Division of Nephrology, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Mi-Kyung Song
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia
| | - Mark Unruh
- Division of Nephrology, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico
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O’Hare AM, Szarka J, McFarland LV, Taylor JS, Sudore RL, Trivedi R, Reinke LF, Vig EK. Provider Perspectives on Advance Care Planning for Patients with Kidney Disease: Whose Job Is It Anyway? Clin J Am Soc Nephrol 2016; 11:855-866. [PMID: 27084877 PMCID: PMC4858488 DOI: 10.2215/cjn.11351015] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2015] [Accepted: 01/21/2015] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES There is growing interest in efforts to enhance advance care planning for patients with kidney disease. Our goal was to elicit the perspectives on advance care planning of multidisciplinary providers who care for patients with advanced kidney disease. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Between April and December of 2014, we conducted semistructured interviews at the Department of Veterans Affairs Puget Sound Health Care System with 26 providers from a range of disciplines and specialties who care for patients with advanced kidney disease. Participants were asked about their perspectives and experiences related to advance care planning in this population. Interviews were audiotaped, transcribed, and analyzed inductively using grounded theory. RESULTS The comments of providers interviewed for this study spoke to significant system-level barriers to supporting the process of advance care planning for patients with advanced kidney disease. We identified four overlapping themes: (1) medical care for this population is complex and fragmented across settings and providers and over time; (2) lack of a shared understanding and vision of advance care planning and its relationship with other aspects of care, such as dialysis decision making; (3) unclear locus of responsibility and authority for advance care planning; and (4) lack of active collaboration and communication around advance care planning among different providers caring for the same patients. CONCLUSIONS The comments of providers who care for patients with advanced kidney disease spotlight both the need for and the challenges to interdisciplinary collaboration around advance care planning for this population. Systematic efforts at a variety of organizational levels will likely be needed to support teamwork around advance care planning among the different providers who care for patients with advanced kidney disease.
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Affiliation(s)
- Ann M. O’Hare
- Center of Innovation for Veteran-Centered and Value-Driven Care
- Hospital and Specialty Medicine Service, and
- Departments of Medicine and
| | - Jackie Szarka
- Center of Innovation for Veteran-Centered and Value-Driven Care
| | | | | | - Rebecca L. Sudore
- Department of Medicine, Division of Geriatrics, University of California, San Francisco, California
- Department of Medicine, San Francisco Department of Veterans Affairs Medical Center, San Francisco, California
| | - Ranak Trivedi
- Center for Innovation to Implementation, Department of Veterans Affairs Palo Alto Health Care System, Palo Alto, California; and
- Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, California
| | - Lynn F. Reinke
- Center of Innovation for Veteran-Centered and Value-Driven Care
- Hospital and Specialty Medicine Service, and
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Culp S, Lupu D, Arenella C, Armistead N, Moss AH. Unmet Supportive Care Needs in U.S. Dialysis Centers and Lack of Knowledge of Available Resources to Address Them. J Pain Symptom Manage 2016; 51:756-761.e2. [PMID: 26706629 DOI: 10.1016/j.jpainsymman.2015.11.017] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Revised: 11/20/2015] [Accepted: 11/21/2015] [Indexed: 11/23/2022]
Abstract
CONTEXT Because of high symptom burden, numerous comorbidities, and shortened life expectancy, dialysis patients are increasingly recognized as appropriate candidates for early and continuous supportive care. OBJECTIVES The objectives of this study were to describe dialysis professionals' perceptions of the adequacy of supportive care in dialysis centers, barriers to providing it, suggestions for improving it, and familiarity with the existing evidence-based resources for supportive care of dialysis patients. METHODS The Coalition for Supportive Care of Kidney Patients conducted an online survey of dialysis professionals and administrators solicited through the 18 End-Stage Renal Disease Networks and the Renal Physicians Association. RESULTS Only 4.5% of 487 respondents believed their dialysis centers were presently providing high-quality supportive care. They identified bereavement support, spiritual support, and end-of-life care discussions as the top three unmet needs. They reported that lack of a predictive algorithm for prognosis was the top barrier, and "guidelines to help with decision-making in seriously ill patients" was the top priority to improve supportive care. A majority of respondents were unaware that an evidence-based validated prognostic model and a clinical practice guideline to help with decision-making were already available. CONCLUSION Dialysis professionals report significant unmet supportive care needs and barriers in their centers with only a small minority rating themselves as competently providing supportive care. There is an urgent need for education of dialysis professionals about available supportive care resources to provide quality supportive care to dialysis patients.
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Affiliation(s)
- Stacey Culp
- Department of Statistics, West Virginia University, Morgantown, West Virginia, USA
| | - Dale Lupu
- Daleview Associates, Silver Spring, Maryland, USA
| | | | | | - Alvin H Moss
- Sections of Nephrology and Supportive Care, West Virginia University School of Medicine, Morgantown, West Virginia, USA.
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48
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Feely MA, Swetz KM, Zavaleta K, Thorsteinsdottir B, Albright RC, Williams AW. Reengineering Dialysis: The Role of Palliative Medicine. J Palliat Med 2016; 19:652-5. [PMID: 26991732 DOI: 10.1089/jpm.2015.0181] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND End-stage renal disease is a life-limiting illness associated with significant morbidity. Half of all individuals with end-stage renal disease are unable to participate in decision making at the end of life, which makes advance care planning critical in this population. OBJECTIVE We sought to determine the feasibility of embedding palliative medicine consultations in the hemodialysis unit during treatment runs and the impact of this intervention on advance care planning and symptom management. DESIGN Single-center, prospective cohort study. SETTING/SUBJECTS Adults receiving in-center hemodialysis at a single outpatient unit were eligible. All consultations occurred during the patients' hemodialysis runs between January 1 and June 30, 2012. MEASUREMENT Medical records were reviewed for documentation of advance directives, resuscitation status, and goals of care discussions before and after palliative medicine intervention. Symptom surveys with the Modified Edmonton Symptom Assessment Scale (validated for end-stage renal disease) were performed preintervention and postintervention. RESULTS Ninety-two patients were eligible; 91 underwent palliative medicine consultation. Symptoms were well controlled at baseline prior to any intervention. After palliative medicine consultation, the prevalence of unknown code status decreased from 23% to 1% and goals of care documentation improved from 3% to 59%. CONCLUSION Palliative medicine consultation during in-center outpatient hemodialysis was well received by patients and clinical staff. Patients' symptoms were well managed at baseline by the primary nephrology team. The frequency of goals of care documentation and clarification of code status improved significantly. Embedded palliative medicine specialists on the dialysis care team may be effective in improving multidisciplinary patient-centered care for patients with end-stage renal disease.
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Affiliation(s)
- Molly A Feely
- 1 Division of General Internal Medicine, Section of Palliative Medicine, Mayo Clinic , Rochester, Minnesota
| | - Keith M Swetz
- 1 Division of General Internal Medicine, Section of Palliative Medicine, Mayo Clinic , Rochester, Minnesota
| | | | | | - Robert C Albright
- 4 Division of Nephrology and Hypertension, Mayo Clinic , Rochester, Minnesota
| | - Amy W Williams
- 4 Division of Nephrology and Hypertension, Mayo Clinic , Rochester, Minnesota
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Cohen RA, Jackson VA, Norwich D, Schell JO, Schaefer K, Ship AN, Sullivan AM. A Nephrology Fellows' Communication Skills Course: An Educational Quality Improvement Report. Am J Kidney Dis 2016; 68:203-211. [PMID: 26994686 DOI: 10.1053/j.ajkd.2016.01.025] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Accepted: 01/24/2016] [Indexed: 11/11/2022]
Abstract
BACKGROUND Nephrology fellows need expertise navigating challenging conversations with patients throughout the course of advanced kidney disease. However, evidence shows that nephrologists receive inadequate training in this area. This study assessed the effectiveness of an educational quality improvement intervention designed to enhance fellows' communication with patients who have advanced kidney disease. STUDY DESIGN Quality improvement project. SETTING & PARTICIPANTS Full-day annual workshops (2013-2014) using didactics, discussion, and practice with simulated patients. Content focused on delivering bad news, acknowledging emotion, discussing care goals in dialysis decision making when prognosis is uncertain, and addressing dialysis therapy withdrawal and end of life. Participants were first-year nephrology fellows from 2 Harvard-affiliated training programs (N=26). QUALITY IMPROVEMENT PLAN Study assessed the effectiveness of an intervention designed to enhance fellows' communication skills. OUTCOMES Primary outcomes were changes in self-reported patient communication skills, attitudes, and behaviors related to discussing disease progression, prognostic uncertainty, dialysis therapy withdrawal, treatments not indicated, and end of life; responding to emotion; eliciting patient goals and values; and incorporating patient goals into recommendations. MEASUREMENTS Surveys measured prior training, pre- and postcourse perceived changes in skills and values, and reported longer term (3-month) changes in communication behaviors, using both closed- and open-ended items. RESULTS Response rates were 100% (pre- and postsurveys) and 68% (follow-up). Participants reported improvement in all domains, with an overall mean increase of 1.1 (summed average scores: precourse, 2.8; postcourse, 3.9 [1-5 scale; 5 = "extremely well prepared"]; P<0.001), with improvement sustained at 3 months. Participants reported meaningful changes integrating into practice specific skills taught, such as "Ask-Tell-Ask" and using open-ended questions. LIMITATIONS Self-reported data may overestimate actual changes; small sample size and the programs' affiliation with a single medical school may limit generalizability. CONCLUSIONS A day-long course addressing nephrology fellows' communication competencies across the full course of patients' illness experience can enhance fellows' self-reported skills and practices.
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Affiliation(s)
- Robert A Cohen
- Nephrology Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
| | - Vicki A Jackson
- Palliative Care Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Diana Norwich
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Jane O Schell
- Section of Palliative Care and Medical Ethics and Renal Division-Electrolyte Division, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Kristen Schaefer
- Division of Psychosocial Medicine and Palliative Care, Dana Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Amy N Ship
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Amy M Sullivan
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
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Kahrass H, Strech D, Mertz M. The Full Spectrum of Clinical Ethical Issues in Kidney Failure. Findings of a Systematic Qualitative Review. PLoS One 2016; 11:e0149357. [PMID: 26938863 PMCID: PMC4777282 DOI: 10.1371/journal.pone.0149357] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Accepted: 01/29/2016] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND When treating patients with kidney failure, unavoidable ethical issues often arise. Current clinical practice guidelines some of them, but lack comprehensive information about the full range of relevant ethical issues in kidney failure. A systematic literature review of such ethical issues supports medical professionalism in nephrology, and offers a solid evidential base for efforts that aim to improve ethical conduct in health care. AIM To identify the full spectrum of clinical ethical issues that can arise for patients with kidney failure in a systematic and transparent manner. METHOD A systematic review in Medline (publications in English or German between 2000 and 2014) and Google Books (with no restrictions) was conducted. Ethical issues were identified by qualitative text analysis and normative analysis. RESULTS The literature review retrieved 106 references that together mentioned 27 ethical issues in clinical care of kidney failure. This set of ethical issues was structured into a matrix consisting of seven major categories and further first and second-order categories. CONCLUSIONS The systematically-derived matrix helps raise awareness and understanding of the complexity of ethical issues in kidney failure. It can be used to identify ethical issues that should be addressed in specific training programs for clinicians, clinical practice guidelines, or other types of policies dealing with kidney failure.
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Affiliation(s)
- Hannes Kahrass
- Institute for History, Ethics and Philosophy in Medicine, Hannover Medical School, Hannover, Germany
| | - Daniel Strech
- Institute for History, Ethics and Philosophy in Medicine, Hannover Medical School, Hannover, Germany
| | - Marcel Mertz
- Institute for History, Ethics and Philosophy in Medicine, Hannover Medical School, Hannover, Germany
- Center for Ethics, University Hospital Cologne, Cologne, Germany
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