Effectiveness of an Advance Care Planning Intervention in Adults Receiving Dialysis and Their Families: A Cluster Randomized Clinical Trial

Frailty as a Predictor of Post-Traumatic Stress Disorder After Advance Care Planning Communication Intervention by Trained Care Managers in Long-Term Care Service Users in Japan: A Secondary Analysis

Background/Objectives: Advance care planning is essential in a community; however, intervention studies by care managers remain scarce. This study aims to determine the relationship between frailty and post-traumatic stress disorder among long-term care service users (hereinafter referred to as "users") following advance care planning conversations with their care managers. Methods: We conducted a secondary analysis using raw data from the Japanese University Hospital Medical Information Network Study No. 000048573, published on 23 September 2024. In this previous study, trained care managers provided advance care planning conversation interventions to 30 users. Care managers conducted a convenience sample of 30 mentally and physically stable users who were 65 years old or older, had a family member or healthcare provider assigned, and had never used ACP. Our analysis in the present study focuses on the Clinical Frailty Scale and Impact of Events Scale-Revised, both of which measure post-traumatic stress disorder. Results: The Impact of Events Scale-Revised score was significantly higher in users with a clinical frailty score ≥ 5 compared to those with a clinical frailty score < 5. Logistic regression analysis, using the Impact of Events Scale-Revised as the objective variable, also revealed an association between a clinical frailty score ≥ 5 and a higher Impact of Events Scale-Revised. The four groups, selected through hierarchical cluster analysis for sensitivity analysis, demonstrated results consistent with the above analysis. Conclusions: The degree of post-traumatic stress disorder among users is associated with their degree of frailty following an advance care planning conversation with their care manager. Frailty in users may be a valuable predictor of stress related to advance care planning conversations. Users with a clinical frailty scale score ≥ 5 can be provided with more personalized care through more careful communication. University Hospital Medical Information Network Trial ID: 000048573.

Effects of dyadic psychoeducational interventions for haemodialysis patients and their family caregivers: a randomised controlled trial

BACKGROUND

Haemodialysis may affect the changes in the patient's relationship with the family, and eventually cause some psychological distress to the patient and affect the health-related quality of life. This study examines the effectiveness of the dyadic psychoeducational intervention on patients' quality of life and psychosocial health, as well as caregiver burden and psychosocial outcomes among caregivers.

METHODS

This is a parallel, two-arm, assessor-blind, randomised controlled trial with a repeated-measures design. A total of 80 haemodialysis dyads (patient and family caregivers) randomly assigned to the intervention group or control group with usual care (N = 40 dyads per group). The intervention included 4-week dyadic psychoeducational intervention. At before intervention (T0), immediately after intervention (T1), 1 month after intervention (T2) and 3 months after intervention (T3), patients' quality of life ana caregiver burden (primary outcomes), and other secondary outcomes (i.e., dyads' coping, depression and anxiety symptoms, and social support) were evaluated. Generalized Estimated Equation was used to test the intervention effect of the dyadic psychoeducation intervention, and intentional-to-treat analysis was used for all analyses.

RESULTS

Effects of dyadic psychoeducational intervention: The result of adjusting the GEE model shows that dyadic psychoeducational intervention can effectively improve patients' quality of life (T1: β = 8.51, p < 0.001; T2: β = 9.03, p < 0.001; T3: β = 8.82, p < 0.001), patients' anxiety (T1: β = -2.35, p = 0.022; T2: β = -2.84, p = 0.002; T3: β = -2.85, p = 0.001) and caregivers' anxiety (T2: β = -1.67, p = 0.012; T3: β = -2.57, p = 0.004), patients' depression (T2: β = -2.39, p = 0.017; T3: β = -2.71, p = 0.006), caregiver burden (T2: β = -6.95, p = 0.007; T3: β = -6.34, p = 0.008), caregiver depression (T2: β = -2.01, p = 0.015; T3: β = -1.85, p = 0.015).

CONCLUSIONS

The dyadic psychoeducational intervention can improve the psychosocial outcomes of haemodialysis dyads. This intervention provides effective ways and measures for the relevant psychological education intervention and provides new ideas and evidence for clinical nursing research.

TRIAL REGISTRATION

This study was retrospectively registered as a randomized controlled trial in the ClinicalTrials Registry. Registration Date: April 16, 2024.

REGISTRATION NUMBER

NCT06203730.

Health system related kidney supportive care interventions for adults with chronic kidney disease: A systematic review

INTRODUCTION

Kidney failure can be managed either conservatively or via kidney replacement therapy. Kidney supportive care combines the expertise of nephrology with palliative care in a multidisciplinary team with a focus on improving quality of life.

OBJECTIVE

To identify and appraise evidence-based health system kidney supportive care interventions DESIGN: Systematic review (PROSPERO Registration - CRD42022333650).

PARTICIPANTS

Adults with chronic kidney failure.

MEASUREMENTS

Six databases were searched, using terms "palliative care" and "chronic kidney disease" for publications between January 2010 and March 2024. The Cochrane "Effective Practice and Organisation of Care" and "Clinical Practice Guidelines for Quality Palliative Care" domains informed data extraction.

RESULTS

Of the 60 studies included, one-third were randomised controlled trials. The most common "Effective Practice and Organisation of Care" domain described was care delivery (58/60). End-of-life care (33/60), and physical aspects of care (19/60), were commonly described "Clinical Practice Guidelines for Quality Palliative Care" domains. Multidisciplinary shared care was highlighted in 26 studies. Least described domains were cultural (0/60) and ethical aspects (3/60). Almost 2/3 (39/60) of studies compared the outcomes of kidney supportive care interventions, and the most common outcome assessed was advance care planning (18/39). Key findings reported integrated palliative care reduced hospital admissions and costs, facilitated better patient-clinician communication, and improved symptom management. Gaps were identified in cultural and ethical/legal aspects of care.

CONCLUSIONS

The studies highlighted the effectiveness of kidney-supportive care interventions in improving patient outcomes, especially in end-of-life care and symptom management. However, significant existing gaps identified necessitate further research.

Implementation of An Advance Care Planning Intervention in Dialysis Clinics

RATIONALE & OBJECTIVE

Sharing Patient's Illness Representations to Increase Trust (SPIRIT) is an evidence-based advance care planning intervention targeting dialysis patients and their surrogate decision-makers. To address SPIRIT's implementation potential, we report on a process evaluation in our recently completed 5-state cluster-randomized trial.

STUDY DESIGN

A descriptive study of implementation within a randomized clinical trial.

SETTING & PARTICIPANTS

231 patient-surrogate dyads and 60 dialysis care providers in the 22 active intervention clinics.

EXPOSURE

Status as a patient/surrogate, care provider, or care provider "champion" who all were randomized to clinics implementing the SPIRIT implementation.

OUTCOME

(1) Intervention reach (eg, number of dyads who received SPIRIT relative to each clinic's census); (2) fidelity (eg, champions' self-evaluation checklists, patient and surrogate surveys); (3) sustainability (patient, surrogate, and dialysis care provider acceptability surveys); and (4) context (eg, clinic characteristics).

RESULTS

Of the 2 SPIRIT sessions, 191 participants (82.7%) completed session 1 and 146 (76.4% of 191) completed the optional session 2. Of the 40 champions, 34 completed at least 1 SPIRIT session 1. Champions reported that all 6 intervention steps were completed in 98% to 100% of their sessions. The median duration of session 1 and session 2 were 60 minutes and 15 minutes, respectively. The acceptability surveys suggested a high level of acceptance by patients, surrogates, and providers. Champions reported the main benefits of SPIRIT to be enhanced learning; communication; and improved relationships for patients, surrogates, and providers. The challenges champions reported were scheduling a time that worked for the patient, surrogate, and champion; feeling torn between SPIRIT and other clinical demands; and the emotional burden on the champions themselves.

LIMITATIONS

The lack of data on actual continued use of SPIRIT and low provider participation in acceptability survey.

CONCLUSIONS

This study suggests that SPIRIT was delivered with high fidelity and was experienced positively by stakeholders. However, challenges such as staffing and emotional burden required clinic-level support and warrant future studies testing implementation strategies to address these barriers.

Hospice Referral Rate Disparities of American Indian/Alaska Native Kidney Transplant Recipients with End-Stage Kidney Disease: A Retrospective Cohort Analysis

INTRODUCTION

American Indian/Alaska Native (AI/AN) persons disproportionately suffer from end-stage kidney disease caused by diabetes (ESKD-D). Kidney transplant is the most desirable option to treating ESKD-D, but remains unattainable for many AI/AN persons, especially in rural South Dakota (SD). Additionally, palliative and hospice care options for AI/AN with any serious illness in SD are largely inaccessible. Moreover, receiving kidney transplant potentially affects hospice referral because of the desire to prolong transplant function. Therefore, the purpose of this study was to compare hospice use rates among AI/AN and non-Hispanic White (NHW) persons with ESKD-D prior to death and determine if differences in referral rates are present for those with and without a prior kidney transplant.

METHODS

Retrospective cohort analysis of United States Renal Data System data from 2000-2021. Data for persons with hospice care, transplant status, place of death, and race were analyzed using chi-squared tests with Yates' continuity correction and the Cochran-Mantel-Haenszel test.

RESULTS

AI/AN persons with ESKD-D were less likely to receive hospice care prior to death compared to NHW persons in both transplant (P < 0.001) and non-transplant (P < 0.001) groups. When comparing transplant and non-transplant groups by hospice use, persons with no previous transplant were more likely to receive hospice care prior to death (P < 0.001).

CONCLUSION

These results confirm the assumptions of significant differences in hospice care use among AI/AN vs NHW who have ESKD-D, including differences between those with a prior transplant. There is a need to expand palliative/hospice care services for persons with a prior kidney transplant.

Advanced Care Planning in Chronic Kidney Disease: Qualitative Impact of the MY WAY Intervention

CONTEXT

Despite recommendations for shared decision-making and advanced care planning (ACP) for people with chronic kidney disease (CKD), such conversations are infrequent. The MY WAY educational and patient coaching intervention aimed to promote high-quality ACP.

OBJECTIVES

This qualitative substudy sought to gain participant feedback on the MY WAY ACP coaching intervention, and how it impacted their wishes, perceptions of kidney care, and factors that helped them reflect on ACP.

METHODS

We conducted semi-structured interviews with participants from the intervention arm of the MY WAY study about their prior experience with ACPs in the context of CKD, impressions of the MY WAY intervention, and outcomes of the MY WAY intervention. We conducted a qualitative thematic analysis of transcribed interviews.

RESULTS

Among 15 intervention participants, the following major themes emerged: 1) Patients with CKD approach ACP with varied experiences; 2) Patients felt the MY WAY coaching intervention supported ACP by reinforcing values; and 3) Patients found the coaching intervention focused on end of life, but not necessarily on decision making regarding CKD.

CONCLUSION

Participants perceived the coaching intervention to have high utility in facilitating ACP, but had a limited impact on CKD-specific decision-making. These findings suggest that the coach plays a crucial role in comfort with ACP conversations and that ACP readiness and engagement may not correlate with treatment preferences or understanding of CKD treatment decisions.

Making advance care planning easier for adults with kidney disease and their clinicians

Advance care planning (ACP) has evolved from a narrow focus on end-of-life preference, such as resuscitation, to a continuum of care planning across the life course. Older adults with kidney disease have high morbidity and mortality, and easy-to-use tools can make ACP easier for patients and clinicians.

Pandemic Effects on Stability of End-of-Life Preferences and Patient-Surrogate Dyad Congruence

CONTEXT

Whether a largescale disaster alters people's previous decisions about their end-of-life care is unknown.

OBJECTIVES

We examined the effects of a disaster, the COVID-19 pandemic, on stability of end-of-life care preferences among dialysis patients and on patient-surrogate goals-of-care congruence.

METHODS

We used a natural experimental design to examine goals-of-care preferences pre- and postexposure to the pandemic during a pragmatic trial testing SPIRIT (sharing patient's illness representations to increase trust), an evidence-based advance care planning (ACP) intervention. There were 151 patient-surrogate dyads who prior to the pandemic lockdown had completed baseline (T1) and postintervention assessments (T2) regarding their goals-of-care preferences in two end-of-life scenarios. Of those 151 dyads, 59 intervention, and 51 usual care dyads consented to be in the present study and completed the goals-of-care tool two additional times, at enrollment (T3) and six months later (T4), along with the COVID stress scale (CSS). Dyad congruence was ascertained by comparing patient and surrogate responses to the goals-of-care tool.

RESULTS

There were no changes over time in the proportions of patients who chose comfort-care-only in the goals-of-care tool. The proportion of patients who chose comfort-care-only and dyad congruence were higher in SPIRIT compared to usual care, but there was no interaction between that treatment effect and exposure to the pandemic. CSS was associated with neither patients' preferences nor dyad congruence.

CONCLUSIONS

The pandemic alone did not appear to influence patients' goals-of-care preferences or dyad congruence. This finding supports the stability of value-based end-of-life preferences in general, even during a disaster.

Measures of Patient and Surrogate Preparedness for End-of-Life Decision-Making

CONTEXT

Reliable and valid measures are critical in accurately assessing outcomes of advance care planning interventions (ACP) for end-of-life (EOL) decision-making.

OBJECTIVES

To develop measures of preparedness for EOL decision-making for patients with end-stage renal disease and their surrogates (an exemplar population).

METHODS

In this 3-phase study, Phases 1 and 2 included a cross-discipline concept analysis of the preparedness construct, item generation for patient and surrogate scales (82 items), evaluation of content validity and readability, cognitive interviewing, and item reduction. In phase 3, the retained 26 patient and 25 surrogate items were administered to 426 patients and 426 surrogates during a multisite trial of an ACP intervention versus care-as-usual and evaluated internal consistency, 2-week test-retest reliability, and construct validity.

RESULTS

Scales were reduced to 20 patient and 19 surrogate items during phase 3. Cronbach's alphas were 0.86 (patient) and 0.90 (surrogate). There was a strong correlation between preparedness at baseline and two weeks for both scales (r = 0.66-0.69, P < 0.001). Confirmatory factor analysis and item-response analyses suggested unidimensionality. A significant correlation was shown between patient preparedness and patient decisional conflict (r = -0.53, P < 0.001), and surrogate preparedness and surrogate decision-making confidence (r = 0.44, P < 0.001). Among those who received the ACP intervention, the effect size of change was medium: Cohen's d = 0.54, P < 0.001 for patients and d = 0.57, P < 0.001 for surrogates.

CONCLUSIONS

The preparedness scales demonstrated strong psychometric properties. Future studies should examine scale performance in other populations.