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Hamroun A, Glowacki F, Frimat L. Comprehensive conservative care: what doctors say, what patients hear. Nephrol Dial Transplant 2023; 38:2428-2443. [PMID: 37156527 DOI: 10.1093/ndt/gfad088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Indexed: 05/10/2023] Open
Abstract
The demographic evolution of patients with advanced chronic kidney disease (CKD) has led to the advent of an alternative treatment option to kidney replacement therapy in the past couple of decades. The KDIGO controversies on Kidney Supportive Care called this approach "comprehensive conservative care" (CCC) and defined it as planned holistic patient-centered care for patients with CKD stage 5 that does not include dialysis. Although the benefit of this treatment option is now well-recognized, especially for the elderly, and comorbid and frail patients, its development remains limited in practice. While shared decision-making and advance care planning represent the cornerstones of the CCC approach, one of the main barriers in its development is the perfectible communication between nephrologists and patients, but also between all healthcare professionals involved in the care of advanced CKD patients. As a result, a significant gap has opened up between what doctors say and what patients hear. Indeed, although CCC is reported by nephrologists to be widely available in their facilities, few of their patients say that they have actually heard of it. The objectives of this review are to explore discrepancies between what doctors say and what patients hear, to identify the factors underlying this gap, and to formulate practical proposals for narrowing this gap in practice.
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Affiliation(s)
- Aghiles Hamroun
- Lille University, Lille University Hospital Center of Lille, Department of Nephrology, Dialysis, Kidney Transplantation, and Apheresis, Lille, France
- University Lille, CNRS, Inserm, CHU Lille, Institut Pasteur de Lille, UMR1167 RID-AGE, F-59000 Lille, France
| | - François Glowacki
- Lille University, Lille University Hospital Center of Lille, Department of Nephrology, Dialysis, Kidney Transplantation, and Apheresis, Lille, France
- University Lille, CNRS, Inserm, CHU Lille, Institut Pasteur de Lille, UMR9020-U1277 - CANTHER - Cancer Heterogeneity, Plasticity and Resistance to Therapies, F-59000 Lille, France
| | - Luc Frimat
- Department of Nephrology, University Hospital of Nancy, Vandoeuvre-lès-Nancy, France
- Inserm, CIC-1433 Clinical Epidemiology, University Hospital of Nancy, Université de Lorraine, Vandœuvre-Lès-Nancy, France
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Al Maraee G, Vangaveti V, Mallett A. Characterising patients and clinician experiences in comprehensive conservative care for kidney failure in Northern Queensland. Intern Med J 2023; 53:1819-1825. [PMID: 36372949 DOI: 10.1111/imj.15977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 10/31/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND Comprehensive conservative care (CCC) is an emerging treatment option in kidney failure (KF), but its implementation has been restricted by a limited understanding of KF populations, outcomes and clinician experiences. AIMS This pilot study aimed to investigate the characteristics of patients who are opting for (CCC) in North Queensland, Australia. It also aimed to highlight clinician factors impacting treatment discussions. METHODS It was an observational study facilitated through an online cross-sectional survey to nephrologists, nephrology advanced trainees and nurse practitioners working across North Queensland. RESULTS Study participants disagreed with the statement that patients commencing dialysis are more likely to have cardiac co-morbidities (46.7%), diabetes (40.0%), stroke (60.0%), liver disease (60.0%), chronic lung disease (53.3%), cognitive impairment (60.0%) and use of mobility aids (80.0%) than those commencing CCC. Conversely, they agreed that patients commencing dialysis are more likely to be independent (66.7%) and living in their private residence (40.0%). The median frailty score in patients choosing dialysis was 3.0 (interquartile range (IQR) 2.8-3.3), while that of patients selecting CCC was 4.5 (IQR 3.8-7.0). Our participants were aware of at least one clinical prognostication tool, and the one most frequently used was the 'Surprise Question' (46.2%, n = 6). Overall, our participants demonstrated low confidence (median 8.0%, IQR 6.0-8.0%) in facilitating CCC discussions. CONCLUSION Patients who are highly co-morbid and frail and have functional impairment are suitable candidates for CCC. More focus needs to be placed on objective prognostication of patients and the upskilling of clinicians to advocate for, and deliver, CCC.
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Affiliation(s)
- Gheed Al Maraee
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Venkat Vangaveti
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Andrew Mallett
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
- Department of Renal Medicine, Townsville University Hospital, Townsville, Queensland, Australia
- Institute for Molecular Bioscience, The University of Queensland, Brisbane, Queensland, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
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Hamroun A, Glowacki F. Comprehensive conservative care for the management of advanced chronic kidney disease: overview and perspectives. Nephrol Ther 2023; 19:1-9. [PMID: 37305992 DOI: 10.1684/ndt.2023.28] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Comprehensive “conservative care” is defined as any active therapeutic procedure for the management of stage 5 chronic kidney disease without recourse to dialysis. This therapeutic option is discussed in elderly, frail patients whose anticipated life expectancy is reduced with dialysis. The decision for conservative management primarily relies on an informed choice by the patient and his caregivers. This holistic approach, focused on quality of life, requires a multidisciplinary approach. The goals are to slow the progression of kidney disease, prevent complications, anticipate the risks of decompensation, provide support for the patient and his caregivers to maintain the best possible quality of life at home. This article describes the principles of conservative management, highlights various barriers to this care pathway, and proposes potential solutions.
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Affiliation(s)
- Aghiles Hamroun
- CHU de Lille, service de santé publique, épidémiologie, économie de la santé et prévention, Lille, France
- UMR1167 RID-AGE, Inserm, Institut Pasteur de Lille, Université de Lille, CHU de Lille, France
| | - François Glowacki
- CHU de Lille, service de néphrologie, dialyse, transplantation rénale et aphérère, Lille, France
- UMR9020-U1277-CANTHER-Cancer Heterogeneity, Plasticity and Resistance to Therapies, Université de Lille, CNRS, Inserm, CHU de Lille, France
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Hamroun A, Speyer E, Ayav C, Combe C, Fouque D, Jacquelinet C, Laville M, Liabeuf S, Massy ZA, Pecoits-Filho R, Robinson BM, Glowacki F, Stengel B, Frimat L. Barriers to conservative care from patients' and nephrologists' perspectives: the CKD-REIN study. Nephrol Dial Transplant 2022; 37:2438-2448. [PMID: 35026014 DOI: 10.1093/ndt/gfac009] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Conservative care is increasingly considered an alternative to kidney replacement therapy for kidney failure management, mostly among the elderly. We investigated its status and the barriers to its implementation from patients' and providers' perspectives. METHODS We analysed data from 1204 patients with advanced chronic kidney disease (CKD) [estimated glomerular filtration rate (eGFR) <30 mL/min/1.73 m2] enrolled at 40 nationally representative nephrology clinics (2013-16) who completed a self-administered questionnaire about the information they received and their preferred treatment option, including conservative care, if their kidneys failed. Nephrologists (n = 137) also reported data about their clinics' resources and practices regarding conservative care. RESULTS All participating facilities reported they were routinely able to offer conservative care, but only 37% had written protocols and only 5% had a person or team primarily responsible for it. Overall, 6% of patients were estimated to use conservative care. Among nephrologists, 82% reported they were fairly or extremely comfortable discussing conservative care, but only 28% usually or always offered this option for older (>75 years) patients approaching kidney failure. They used various terminology for this care, with conservative management and non-dialysis care mentioned most often. Among patients, 5% of those >75 years reported receiving information about this option and 2% preferring it. CONCLUSIONS Although reported by nephrologists to be widely available and easily discussed, conservative care is only occasionally offered to older patients, most of whom report they were not informed of this option. The lack of a person or team responsible for conservative care and unclear information appear to be key barriers to its implementation.
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Affiliation(s)
- Aghilès Hamroun
- Université Paris-Saclay, UVSQ, Université Paris-Sud, Inserm, Équipe Epidémiologie Clinique, CESP, Villejuif, France.,Lille University, University Hospital of Lille, Nephrology Department, Lille, France
| | - Elodie Speyer
- Université Paris-Saclay, UVSQ, Université Paris-Sud, Inserm, Équipe Epidémiologie Clinique, CESP, Villejuif, France
| | - Carole Ayav
- CHRU-Nancy, INSERM, CIC 1433, Epidémiologie Clinique, Nancy, France
| | - Christian Combe
- Service de Néphrologie Transplantation Dialyse Aphérèse, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France.,Inserm U1026, Université de Bordeaux, Bordeaux, France
| | - Denis Fouque
- Service de Néphrologie, Centre Hospitalier Lyon Sud, Pierre-Bénite, France.,Université Claude Bernard Lyon 1, Carmen INSERM U1060, Pierre-Bénite, France
| | | | - Maurice Laville
- Université Claude Bernard Lyon 1, Carmen INSERM U1060, Pierre-Bénite, France
| | - Sophie Liabeuf
- Service de Pharmacologie Clinique, Département de recherche clinique CHU Amiens-Picardie, Amiens, France.,Laboratoire MP3CV, EA7517, Université de Picardie Jules Verne, Amiens, France
| | - Ziad A Massy
- Université Paris-Saclay, UVSQ, Université Paris-Sud, Inserm, Équipe Epidémiologie Clinique, CESP, Villejuif, France.,Service de néphrologie, Hôpital Ambroise Paré, AP-HP, Boulogne-Billancourt, France
| | | | | | - François Glowacki
- Lille University, University Hospital of Lille, Nephrology Department, Lille, France
| | - Bénédicte Stengel
- Université Paris-Saclay, UVSQ, Université Paris-Sud, Inserm, Équipe Epidémiologie Clinique, CESP, Villejuif, France
| | - Luc Frimat
- Service de Néphrologie, CHRU de Nancy, Vandoeuvre-lès-Nancy, France.,Université de Lorraine, APEMAC, Nancy, France
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Frazier R, Levine S, Porteny T, Tighiouart H, Wong JB, Isakova T, Koch-Weser S, Gordon EJ, Weiner DE, Ladin K. Shared Decision Making Among Older Adults With Advanced CKD. Am J Kidney Dis 2022; 80:599-609. [PMID: 35351579 DOI: 10.1053/j.ajkd.2022.02.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 02/09/2022] [Indexed: 02/02/2023]
Abstract
RATIONALE & OBJECTIVE Older adults with advanced chronic kidney disease (CKD) face difficult decisions about dialysis initiation. Although shared decision making (SDM) can help align patient preferences and values with treatment options, the extent to which older patients with CKD experience SDM remains unknown. STUDY DESIGN A cross-sectional analysis of patient surveys examining decisional readiness, treatment options education, care partner support, and SDM. SETTING & PARTICIPANTS Adults aged 70 years or older from Boston, Chicago, San Diego, or Portland (Maine) with nondialysis advanced CKD. PREDICTORS Decisional readiness factors, treatment options education, and care partner support. OUTCOMES Primary: SDM measured by the 9-item Shared Decision Making Questionnaire (SDM-Q-9) instrument, with higher scores reflecting greater SDM. Exploratory: Factors associated with SDM. ANALYTICAL APPROACH We used multivariable linear regression models to examine the associations between SDM and predictors, controlling for demographic and health factors. RESULTS Among 350 participants, mean age was 78 ± 6 years, 58% were male, 13% identified as Black, and 48% had diabetes. Mean SDM-Q-9 score was 52 ± 28. SDM item agreement ranged from 41% of participants agreeing that "my doctor and I selected a treatment option together" to 73% agreeing that "my doctor told me that there are different options for treating my medical condition." In multivariable analysis adjusted for demographic characteristics, lower estimated glomerular filtration rate, and diabetes, being "well informed" and "very well informed" about kidney treatment options, having higher decisional certainty, and attendance at a kidney treatment options class were independently associated with higher SDM-Q-9 scores. LIMITATIONS The cross-sectional study design limits the ability to make temporal associations between SDM and the predictors. CONCLUSIONS Many older patients with CKD do not experience SDM when making dialysis decisions, emphasizing the need for greater access to and delivery of education for individuals with advanced CKD.
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Affiliation(s)
- Rebecca Frazier
- Division of Nephrology and Hypertension, Department of Medicine, Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Chicago, Illinois; Jesse Brown Veterans Administration Medical Center, Chicago, Illinois.
| | - Sarah Levine
- William B. Schwartz MD Division of Nephrology, Tufts University School of Medicine, Boston, Massachusetts
| | - Thalia Porteny
- Research on Ethics, Aging, and Community Health (REACH Lab) and Departments of Occupational Therapy and Community Health, Tufts University, Medford, Massachusetts
| | - Hocine Tighiouart
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts; Tufts Clinical and Translational Science Institute, Tufts University, Tufts University School of Medicine, Boston, Massachusetts
| | - John B Wong
- Division of Clinical Decision Making, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts
| | - Tamara Isakova
- Division of Nephrology and Hypertension, Department of Medicine, Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Chicago, Illinois
| | - Susan Koch-Weser
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, Massachusetts
| | - Elisa J Gordon
- Department of Surgery-Division of Transplantation, Center for Health Services and Outcomes Research, Center for Bioethics and Medical Humanities, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Daniel E Weiner
- William B. Schwartz MD Division of Nephrology, Tufts University School of Medicine, Boston, Massachusetts
| | - Keren Ladin
- Research on Ethics, Aging, and Community Health (REACH Lab) and Departments of Occupational Therapy and Community Health, Tufts University, Medford, Massachusetts
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Buades JM, Craver L, Del Pino MD, Prieto-Velasco M, Ruiz JC, Salgueira M, de Sequera P, Vega N. Management of Kidney Failure in Patients with Diabetes Mellitus: What Are the Best Options? J Clin Med 2021; 10:2943. [PMID: 34209083 PMCID: PMC8268456 DOI: 10.3390/jcm10132943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Revised: 06/22/2021] [Accepted: 06/25/2021] [Indexed: 11/25/2022] Open
Abstract
Diabetic kidney disease (DKD) is the most frequent cause of kidney failure (KF). There are large variations in the incidence rates of kidney replacement therapy (KRT). Late referral to nephrology services has been associated with an increased risk of adverse outcomes. In many countries, when patients reach severely reduced glomerular filtration rate (GFR), they are managed by multidisciplinary teams led by nephrologists. In these clinics, efforts will continue to halt chronic kidney disease (CKD) progression and to prevent cardiovascular mortality and morbidity. In patients with diabetes and severely reduced GFR and KF, treating hyperglycemia is a challenge, since some drugs are contraindicated and most of them require dose adjustments. Even more, a decision-making process will help in deciding whether the patient would prefer comprehensive conservative care or KRT. On many occasions, this decision will be conditioned by diabetes mellitus itself. Effective education should cover the necessary information for the patient and family to answer these questions: 1. Should I go for KRT or not? 2. If the answer is KRT, dialysis and/or transplantation? 3. Dialysis at home or in center? 4. If dialysis at home, peritoneal dialysis or home hemodialysis? 5. If transplantation is desired, discuss the options of whether the donation would be from a living or deceased donor. This review addresses the determinant factors with an impact on DKD, aiming to shed light on the specific needs that arise in the management and recommendations on how to achieve a comprehensive approach to the diabetic patient with chronic kidney disease.
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Affiliation(s)
- Juan M. Buades
- Department of Nephrology, Hospital Universitario Son Llàtzer, Balearic Islands, 07198 Palma de Mallorca, Spain
- Health Research Institute of the Balearic Islands (IdISBa), 07120 Palma de Mallorca, Spain
| | - Lourdes Craver
- Department of Nephrology, Hospital Universitario Arnau de Vilanova, 25198 Lleida, Spain;
| | - Maria Dolores Del Pino
- Department of Nephrology, Complejo Hospitalario Torrecárdenas de Almería, 04009 Almería, Spain;
| | - Mario Prieto-Velasco
- Department of Nephrology, Complejo Asistencial Universitario de Leon, 24001 León, Spain;
| | - Juan C. Ruiz
- Department of Nephrology, Valdecilla Hospital, University of Cantabria, 39008 Santander, Spain;
- Valdecilla Biomedical Research Institute (IDIVAL), Cardenal Herrera Oria S/N, 39011 Santander, Spain
| | - Mercedes Salgueira
- Department of Nephrology, Hospital Universitario Virgen Macarena, 41009 Seville, Spain;
- Biomedical Engineering Group, Medicine Department, University of Seville, 41092 Seville, Spain
- Center for Biomedical Research Network in Bioengineering Biomaterials and Nanomedicina (CIBER-BBN), 28029 Madrid, Spain
| | - Patricia de Sequera
- Department of Nephrology, Hospital Universitario Infanta Leonor, 28031 Madrid, Spain;
- Medicine Department, Universidad Complutense de Madrid, 28031 Madrid, Spain
| | - Nicanor Vega
- Department of Nephrology, Hospital Universitario de Gran Canaria Dr. Negrín, 35010 Las Palmas de Gran Canaria, Spain;
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Diamond LH, Armistead NC, Lupu DE, Moss AH. Recommendations for Public Policy Changes to Improve Supportive Care for Seriously Ill Patients With Kidney Disease. Am J Kidney Dis 2020; 77:529-537. [PMID: 33278476 DOI: 10.1053/j.ajkd.2020.09.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 09/29/2020] [Indexed: 01/03/2023]
Abstract
National and international nephrology organizations have identified substantial unmet supportive care needs of patients with kidney disease and issued recommendations. In the United States, the most recent comprehensive effort to change kidney care, the Advancing American Kidney Health Initiative, does not explicitly address supportive care needs, although it attempts to implement more patient-centered care. This Perspective from the leaders of the Coalition for Supportive Care of Kidney Patients advocates for urgent policy changes to improve patient-centered care and the quality of life of seriously ill patients with kidney disease. It argues for the provision of supportive care by an interdisciplinary team led by nephrology clinicians to improve shared decision-making, advance care planning, pain and symptom management, the explicit offering of active medical management without dialysis as an option for patients who may not benefit from dialysis, and the removal by the Centers for Medicare & Medicaid Services and all other payors of financial and regulatory disincentives to quality supportive care, including hospice, for patients with or approaching kidney failure. It also emphasizes that all educational and accreditation programs for nephrology clinicians include kidney supportive care and its essential role in the care of patients with kidney disease.
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Affiliation(s)
- Louis H Diamond
- Center for Aging, Health and Humanities, George Washington University School of Nursing, Washington, DC; Coalition for Supportive Care of Kidney Patients, Washington, DC
| | - Nancy C Armistead
- Center for Aging, Health and Humanities, George Washington University School of Nursing, Washington, DC; Coalition for Supportive Care of Kidney Patients, Washington, DC
| | - Dale E Lupu
- Center for Aging, Health and Humanities, George Washington University School of Nursing, Washington, DC; Coalition for Supportive Care of Kidney Patients, Washington, DC
| | - Alvin H Moss
- Coalition for Supportive Care of Kidney Patients, Washington, DC; Center for Health Ethics and Law, West Virginia University School of Medicine, Morgantown, WV.
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Bradshaw CL, Gale RC, Chettiar A, Ghaus SJ, Thomas IC, Fung E, Lorenz K, Asch SM, Anand S, Kurella Tamura M. Medical Record Documentation of Goals-of-Care Discussions Among Older Veterans With Incident Kidney Failure. Am J Kidney Dis 2019; 75:744-752. [PMID: 31679746 DOI: 10.1053/j.ajkd.2019.07.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 07/26/2019] [Indexed: 11/11/2022]
Abstract
RATIONALE & OBJECTIVE Elicitation and documentation of patient preferences is at the core of shared decision making and is particularly important among patients with high anticipated mortality. The extent to which older patients with incident kidney failure undertake such discussions with their providers is unknown and its characterization was the focus of this study. STUDY DESIGN Retrospective cohort study. SETTING & PARTICIPANTS A random sample of veterans 67 years and older with incident kidney failure receiving care from the US Veterans Health Administration between 2005 and 2010. EXPOSURES Demographic and facility characteristics, as well as predicted 6-month mortality risk after dialysis initiation and documentation of resuscitation preferences. OUTCOMES Documented discussions of dialysis treatment and supportive care. ANALYTICAL APPROACH We reviewed medical records over the 2 years before incident kidney failure and up to 1 year afterward to ascertain the frequency and timing of documented discussions about dialysis treatment, supportive care, and resuscitation. Logistic regression was used to identify factors associated with these documented discussions. RESULTS The cohort of 821 veterans had a mean age of 80.9±7.2 years, and 37.2% had a predicted 6-month mortality risk>20% with dialysis. Documented discussions addressing dialysis treatment and resuscitation were present in 55.6% and 77.1% of patients, respectively. Those addressing supportive care were present in 32.4%. The frequency of documentation varied by mortality risk and whether the patient ultimately started dialysis. In adjusted analyses, the frequency and pattern of documentation were more strongly associated with geographic location and receipt of outpatient nephrology care than with patient demographic or clinical characteristics. LIMITATIONS Documentation may not fully reflect the quality and content of discussions, and generalizability to nonveteran patients is limited. CONCLUSIONS Among older veterans with incident kidney failure, discussions of dialysis treatment are decoupled from other aspects of advance care planning and are suboptimally documented, even among patients at high risk for mortality.
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Affiliation(s)
| | - Randall C Gale
- Center for Innovation to Implementation, VA Palo Alto VA Health Care System, Palo Alto, CA
| | - Alexis Chettiar
- Program of Health Policy, University of California San Francisco, San Francisco, CA
| | - Sharfun J Ghaus
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA
| | - I-Chun Thomas
- Geriatric Research and Education Clinical Center, VA Palo Alto Health Care System, Palo Alto, CA
| | - Enrica Fung
- Division of Nephrology, VA Loma Linda Healthcare System, Loma Linda, CA
| | - Karl Lorenz
- Geriatric Research and Education Clinical Center, VA Palo Alto Health Care System, Palo Alto, CA
| | - Steven M Asch
- Center for Innovation to Implementation, VA Palo Alto VA Health Care System, Palo Alto, CA
| | - Shuchi Anand
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA
| | - Manjula Kurella Tamura
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA; Geriatric Research and Education Clinical Center, VA Palo Alto Health Care System, Palo Alto, CA
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