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Jongejan M, de Lange S, Bos WJW, Pieterse AH, Konijn WS, van Buren M, Abrahams AC, van Oevelen M. Choosing conservative care in advanced chronic kidney disease: a scoping review of patients' perspectives. Nephrol Dial Transplant 2024; 39:659-668. [PMID: 37669893 DOI: 10.1093/ndt/gfad196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Indexed: 09/07/2023] Open
Abstract
BACKGROUND Conservative care (CC) is a viable treatment option for some patients with kidney failure. Choosing between dialysis and CC can be a complex decision in which involvement of patients is desirable. Gaining insight into the experiences and preferences of patients regarding this decision-making process is an important initial step to improve care. We aimed to identify what is known about the perspective of patients regarding decision-making when considering CC. METHODS PubMed, EMBASE and Cochrane databases were systematically searched on 23 February 2023 for qualitative and quantitative studies on patient-reported experiences on decision-making about CC. Data were analysed thematically. RESULTS Twenty articles were included. We identified three major themes: creating awareness about disease and treatment choice, decision support and motivation to choose CC. Patients were often not aware of the option to choose CC. Patients felt supported by their loved ones during the decision-making process, although they perceived they made the final decision to choose CC themselves. Some patients felt pressured by their healthcare professional to choose dialysis. Reported reasons to choose CC were maintaining quality of life, treatment burden of dialysis, cost and the desire not to be a burden to others. In general, patients were satisfied with their decision for CC. CONCLUSIONS By focussing on the perspective of patients, we identified a wide range of patient experiences and preferences regarding the decision-making process. These findings can help to improve the complex decision-making process between dialysis and CC and to provide patient-centred care.
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Affiliation(s)
- Micha Jongejan
- Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Sanne de Lange
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Willem Jan W Bos
- Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
- Department of Internal Medicine, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Arwen H Pieterse
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Wanda S Konijn
- Dutch Kidney Patient Association (NVN), Bussum, The Netherlands
| | - Marjolijn van Buren
- Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
- Department of Nephrology, Haga Hospital, The Hague, The Netherlands
| | - Alferso C Abrahams
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Mathijs van Oevelen
- Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
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Gonzales KM, Koch-Weser S, Kennefick K, Lynch M, Porteny T, Tighiouart H, Wong JB, Isakova T, Rifkin DE, Gordon EJ, Rossi A, Weiner DE, Ladin K. Decision-Making Engagement Preferences among Older Adults with CKD. J Am Soc Nephrol 2024:00001751-990000000-00271. [PMID: 38517479 DOI: 10.1681/asn.0000000000000341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 03/18/2024] [Indexed: 03/23/2024] Open
Abstract
Key Points
Clinicians’ uncertainty about the degree to which older patients prefer to engage in decision making remains a key barrier to shared decision making.Most older adults with advanced CKD preferred a collaborative or active role in decision making.
Background
Older adults with kidney failure face preference-sensitive decisions regarding dialysis initiation. Despite recommendations, few older patients with kidney failure experience shared decision making. Clinician uncertainty about the degree to which older patients prefer to engage in decision making remains a key barrier.
Methods
This study follows a mixed-methods explanatory, longitudinal, sequential design at four diverse US centers with patients (English-fluent, aged ≥70 years, CKD stages 4–5, nondialysis) from 2018 to 2020. Patient preferences for engagement in decision making were assessed using the Control Preferences Scale, reflecting the degree to which patients want to be involved in their decision making: active (the patient prefers to make the final decision), collaborative (the patient wants to share decision making with the clinician), or passive (the patient wants the clinician to make the final decision) roles. Semistructured interviews about engagement and decision making were conducted in two waves (2019, 2020) with purposively sampled patients and clinicians. Descriptive statistics and ANOVA were used for quantitative analyses; thematic and narrative analyses were used for qualitative data.
Results
Among 363 patient participants, mean age was 78±6 years, 42% were female, and 21% had a high school education or less. Control Preferences Scale responses reflected that patients preferred to engage actively (48%) or collaboratively (43%) versus passively (8%). Preferred roles remained stable at 3-month follow-up. Seventy-six participants completed interviews (45 patients, 31 clinicians). Four themes emerged: control preference roles reflect levels of decisional engagement; clinicians control information flow, especially about prognosis; adapting a clinical approach to patient preferred roles; and clinicians' responsiveness to patient preferred roles supports patients' satisfaction with shared decision making.
Conclusions
Most older adults with advanced CKD preferred a collaborative or active role in decision making. Appropriately matched information flow with patient preferences was critical for satisfaction with shared decision making.
Clinical Trial registry name and registration number:
Decision Aid for Renal Therapy (DART), NCT03522740.
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Affiliation(s)
- Kristina M Gonzales
- Department of Community Health, Tufts University, Medford, Massachusetts
- Research on Ethics, Aging, and Community Health (REACH Lab), Medford, Massachusetts
| | - Susan Koch-Weser
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, Massachusetts
| | - Kristen Kennefick
- Research on Ethics, Aging, and Community Health (REACH Lab), Medford, Massachusetts
| | - Mary Lynch
- Research on Ethics, Aging, and Community Health (REACH Lab), Medford, Massachusetts
| | - Thalia Porteny
- Mailman School of Public Health, Columbia University, New York, New York
| | - Hocine Tighiouart
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts
- Tufts Clinical and Translational Science Institute, Tufts University, Boston, Massachusetts
| | - John B Wong
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts
- Tufts Clinical and Translational Science Institute, Tufts University, Boston, Massachusetts
| | - Tamara Isakova
- Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Dena E Rifkin
- Division of Nephrology, Veterans' Affairs Healthcare System, University of California, San Diego, San Diego, California
| | - Elisa J Gordon
- Department of Surgery, Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ana Rossi
- Piedmont Transplant Institute, Atlanta, Georgia
| | - Daniel E Weiner
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | - Keren Ladin
- Department of Community Health, Tufts University, Medford, Massachusetts
- Research on Ethics, Aging, and Community Health (REACH Lab), Medford, Massachusetts
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Chotivatanapong J, Prince DK, Davison SN, Kestenbaum BR, Oestreich T, Wong SP. A National Survey of Conservative Kidney Management Practices for Patients Who Forgo RRT. KIDNEY360 2024; 5:363-369. [PMID: 38254255 PMCID: PMC11000734 DOI: 10.34067/kid.0000000000000367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 01/12/2024] [Indexed: 01/24/2024]
Abstract
Key Points In the largest survey of US nephrology providers on conservative kidney management (CKM), most reported limited experience with CKM and varied approaches and local resources to provide CKM. There is need to enhance provider training and surveillance of CKM practices and to develop models of CKM that optimize care delivery and outcomes for these patients. Background Clinical practice guidelines advocate for conservative kidney management (CKM), a planned, holistic, patient-centered approach to caring for patients who forgo initiation of RRT. Little is known about the extent to which current care practices meet these expectations. Methods We conducted a cross-sectional survey of a national sample of nephrology providers recruited through US professional societies between March and July 2022 and inquired about their experiences with caring for patients who forgo RRT and their capacity to provide CKM. Results Overall, 203 nephrology providers (age 47±12 years, 53.2% White, 66.0% female), of which 49.8% were nephrologists and 50.2% advanced practice providers, completed the survey. Most (70.3%) reported that <10% of their practice comprised patients who had forgone RRT. Most indicated that they always or often provided symptom management (81.8%), multidisciplinary care (68.0%), tools to support shared decision making about treatment of advanced kidney disease (66.3%), and psychological support (52.2%) to patients who forgo RRT, while less than half reported that they always or often provided staff training on the care of these patients (47.8%) and spiritual support (41.4%). Most providers reported always or often working with primary care (72.9%), palliative medicine (68.8%), hospice (62.6%), social work (58.1%), and dietitian (50.7%) services to support these patients, while only a minority indicated that they always or often offered chaplaincy (23.2%), physical and/or occupational therapy (22.8%), psychology or psychiatry (31.5%), and geriatric medicine (28.1%). Conclusions Many nephrology providers have limited experience with caring for patients who forgo RRT. Our findings highlight opportunities to optimize comprehensive CKM care for these patients.
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Affiliation(s)
| | - David K. Prince
- Department of Medicine, University of Washington, Seattle, Washington
| | - Sara N. Davison
- Department of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | | | - Taryn Oestreich
- Department of Medicine, University of Washington, Seattle, Washington
| | - Susan P.Y. Wong
- Department of Medicine, University of Washington, Seattle, Washington
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Sakthivel P, Mostafa A, Aiyegbusi OL. Factors that influence the selection of conservative management for end-stage renal disease - a systematic review. Clin Kidney J 2024; 17:sfad269. [PMID: 38186878 PMCID: PMC10768754 DOI: 10.1093/ckj/sfad269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Indexed: 01/09/2024] Open
Abstract
Background Most patients with end-stage renal disease (ESRD) are managed with dialysis and less commonly kidney transplantation. However, not all are suitable for or desire either of these renal replacement therapies. Conservative management (CM) is an option. However, the selection of CM is often not easy for patients and clinicians. The aim of this systematic review is to identify the key factors that influence the selection of CM for ESRD. Methods Medline, Embase, PsychINFO, and CINAHL Plus were systematically searched from inception to 10 September 2021. Titles/abstracts and full texts were independently screened by two reviewers. Reference lists of included articles were searched. An update search via PubMed was conducted on 10 August 2023. A narrative synthesis of review findings was conducted. Results At the end of the screening process, 15 qualitative and 8 survey articles were selected. Reference checking yielded no additional relevant studies. Main themes were: (i) Patient-specific factors; (ii) Clinician-specific factors; (iii) Organisational factors; and (iv) National and international factors. Patient-specific factors were awareness and perceptions of CM and dialysis, beliefs about survival, preferred treatment outcomes and influence of family/caregivers and clinicians. Clinician-specific factors included perceptions of CM as 'non-intervention', perceptions of clinician role in the decision-making process, and confidence and ability to initiate sensitive treatment discussions. Relationships with and involvement of other healthcare professionals, time constraints, and limited clinical guidance were also important factors. Conclusions An improvement in the provision of education regarding CM for patients, caregivers, and clinicians is essential. Robust studies are required to generate crucial evidence for the development of stronger recommendations and guidance for clinicians.
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Affiliation(s)
- Pavithra Sakthivel
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Alyaa Mostafa
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Olalekan Lee Aiyegbusi
- Centre for Patient Reported Outcomes Research, University of Birmingham, Edgbaston, Birmingham, UK
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre (BRC), University of Birmingham, Birmingham, UK
- NIHR Applied Research Collaboration (ARC) West Midlands, Birmingham, UK
- Birmingham Health Partners Centre for Regulatory Science and Innovation, University of Birmingham, Birmingham, UK
- NIHR Blood and Transplant Research Unit (BTRU) in Precision Therapeutics, University of Birmingham, Birmingham, UK
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Scherer JS, Bieber B, de Pinho NA, Masud T, Robinson B, Pecoits-Filho R, Schiedell J, Goldfeld K, Chodosh J, Charytan DM. Conservative Kidney Management Practice Patterns and Resources in the United States: A Cross-Sectional Analysis of CKDopps (Chronic Kidney Disease Outcomes and Practice Patterns Study) Data. Kidney Med 2023; 5:100726. [PMID: 37928753 PMCID: PMC10624579 DOI: 10.1016/j.xkme.2023.100726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023] Open
Abstract
Rationale & Objective Conservative kidney management (CKM) is a viable treatment option for many patients with chronic kidney disease. However, CKM practices and resources in the United States are not well described. We undertook this study to gain a better understanding of factors influencing uptake of CKM by describing: (1) characteristics of patients who choose CKM, (2) provider practice patterns relevant to CKM, and (3) CKM resources available to providers. Study Design Cross-sectional study. Setting & Participants This study is a cross-sectional analysis of data from US nephrology clinics enrolled in the chronic kidney disease Outcomes and Practice Patterns Study (CKDopps) collected between 2014 and 2020. Data for this study includes chart-abstracted characteristics of patients with an estimated glomerular filtration rate ≤30mL/min/1.73m2 (n=1018) and available information on whether a decision had been made to pursue CKM at the time of kidney failure, patient (n=407) reports of discussions about forgoing dialysis, and provider (n=26) responses about CKM delivery and available resources in their health systems. Analytical Approach Descriptive statistics were used to report patient demographics, clinical information, provider demographics, and clinic characteristics. Results Among data from 1018 patients, 68 (7%) were recorded as planning for CKM. These patients were older, had more comorbidities, and were more likely to require assistance with transfers. Of the 407 patient surveys, 18% reported a conversation about forgoing dialysis with their nephrologist. A majority of providers felt comfortable discussing CKM; however, no clinics had a dedicated clinic or protocol for CKM. Limitations Inconsistent survey terminology and unlinked patient and provider responses. Conclusions Few patients reported discussion of forgoing dialysis with their providers and even fewer anticipated a choice of CKM on reaching kidney failure. Most providers were comfortable discussing CKM, but practiced in clinics that lacked dedicated resources. Further research is needed to improve the implementation of a CKM pathway. Plain-Language Summary For older comorbid adults with kidney failure, conservative kidney management (CKM) can be an appropriate treatment choice. CKM is a holistic approach with treatment goals of maximizing quality of life and preventing progression of chronic kidney disease (CKD) without initiation of dialysis. We investigated US CKM practices and found that among 1018 people with CKD, only 7% were planning for CKM. Of 407 surveyed patients, 18% reported a conversation with their provider about forgoing dialysis. In contrast, most providers felt comfortable discussing CKM; however, none reported working in an environment with a dedicated CKM clinic or protocol. Our data show the need for further CKM education in the United States as well as dedicated resources for its delivery.
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Affiliation(s)
- Jennifer S. Scherer
- NYU Grossman School of Medicine, Department of Internal Medicine, Division of Geriatrics and Palliative Care, New York, NY
- NYU Grossman School of Medicine, Department of Internal Medicine, Division of Nephrology, New York, NY
| | - Brian Bieber
- Arbor Research Collaborative for Health, Ann Arbor, MI
| | - Natalia Alencar de Pinho
- CESP (Centre de Recherche en Epidémiologie et Santé des Populations), Université Paris Saclay, Université Versailles Saint-Quentin en Yvelines, Institut national de la santé et de la recherche médicale (Inserm), Equipe Epidémiologie Clinique, Villejuif, France
| | - Tahsin Masud
- Emory University, Department of Internal Medicine, Atlanta, GA
| | - Bruce Robinson
- University of Michigan, Department of Internal Medicine, Division of Nephrology, Ann Arbor, MI
| | | | - Joy Schiedell
- NYU Grossman School of Medicine, Department of Population Health, Division of Biostatistics, New York, NY
| | - Keith Goldfeld
- NYU Grossman School of Medicine, Department of Population Health, Division of Biostatistics, New York, NY
| | - Joshua Chodosh
- NYU Grossman School of Medicine, Department of Internal Medicine, Division of Geriatrics and Palliative Care, New York, NY
- VA New York Harbor Healthcare System, New York, NY
| | - David M. Charytan
- NYU Grossman School of Medicine, Department of Internal Medicine, Division of Nephrology, New York, NY
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6
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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] [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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Beckwith H, Thind A, Brown EA. Perceived Life Expectancy Among Dialysis Recipients: A Scoping Review. Kidney Med 2023; 5:100687. [PMID: 37455792 PMCID: PMC10345159 DOI: 10.1016/j.xkme.2023.100687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023] Open
Abstract
Rationale & Objective Greater prognostic understanding is associated with higher quality care at the end of life. We undertook a scoping review to explore how long dialysis recipients expect to live. Study Design Scoping Review. Setting & Study Populations People with kidney failure over 18 years old. Search Strategy & Sources Studies were identified by searching Medline, Embase, APA PsycINFO, HMIC, and ProQuest database for terms related to "life expectancy", "self-estimated", and "end stage kidney disease". Data Extraction Search strategies reported 349 unique, potentially eligible studies, with 8 studies meeting the inclusion criteria after screening. Results Significant mismatches between dialysis recipients and their health care provider's estimations of prognosis were reported, with patients predicting significantly higher life expectancies than health care professionals and almost no agreement between patient and nephrologist's estimates of 1-year survival. Documented cognitive impairment did not affect 1-year or 5-year prognosis estimates, nor did gender, age, time on dialysis, or discussing perceived life expectancy. Dialysis recipients who thought they were on the transplant list or who self-identified as African American reported higher perceived life expectancy, whereas people who were 75 years or older, or with fair or poor self-reported health status reported a lower perceived life expectancy. Those with a lower perceived life expectancy preferred care focusing on relieving pain and discomfort, whereas people who thought they had a higher chance of survival were significantly more likely to prefer life-extending care. Limitations There is a marked paucity of research in this area, with most studies conducted in North American cohorts. Conclusions Optimistic patient prognostic expectations persist in dialysis recipients. Given the effects of perceived life expectancy on treatment choices and subsequent quality of life, it is important that transparent discussions regarding prognosis are conducted with people receiving dialysis and their families. Plain-Language Summary Understanding illness severity and prognosis allows people to make decisions and prioritize areas of their lives that are important to them. We undertook a scoping review to explore how long dialysis recipients expect to live. We found significant mismatches between the perceived life expectancy of people treated with dialysis and their health care providers. Perceived life expectancy influenced treatment choices; thus, those who thought they would die sooner prioritized care focusing on relieving pain and discomfort. Those who thought they had a higher chance of survival were more likely to prefer life-extending care (with potential effects on quality of life). It is important to have frank discussions about prognosis with people receiving dialysis, to empower individuals and help them make informed decisions about their care.
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Affiliation(s)
- Hannah Beckwith
- Renal Department, Imperial College Healthcare NHS Trust, London, United Kingdom
- Department of Renal Medicine, Imperial College London, London, United Kingdom
| | - Amarpreet Thind
- Renal Department, Imperial College Healthcare NHS Trust, London, United Kingdom
- Department of Renal Medicine, Imperial College London, London, United Kingdom
| | - Edwina A. Brown
- Renal Department, Imperial College Healthcare NHS Trust, London, United Kingdom
- Department of Renal Medicine, Imperial College London, London, United Kingdom
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Wong SPY, Prince DK, Kurella Tamura M, Hall YN, Butler CR, Engelberg RA, Vig EK, Curtis JR, O’Hare AM. Value Placed on Comfort vs Life Prolongation Among Patients Treated With Maintenance Dialysis. JAMA Intern Med 2023; 183:462-469. [PMID: 36972031 PMCID: PMC10043804 DOI: 10.1001/jamainternmed.2023.0265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Accepted: 01/29/2023] [Indexed: 03/29/2023]
Abstract
Importance Patients receiving maintenance dialysis experience intensive patterns of end-of-life care that might not be consistent with their values. Objective To evaluate the association of patients' health care values with engagement in advance care planning and end-of-life care. Design, Setting, and Participants Survey study of patients who received maintenance dialysis between 2015 and 2018 at dialysis centers in the greater metropolitan areas of Seattle, Washington, and Nashville, Tennessee, with longitudinal follow-up of decedents. Logistic regression models were used to estimate probabilities. Data analysis was conducted between May and October 2022. Exposures A survey question about the value that the participant would place on longevity-focused vs comfort-focused care if they were to become seriously ill. Main Outcomes and Measures Self-reported engagement in advance care planning and care received near the end of life through 2020 using linked kidney registry data and Medicare claims. Results Of 933 patients (mean [SD] age, 62.6 [14.0] years; 525 male patients [56.3%]; 254 [27.2%] identified as Black) who responded to the question about values and could be linked to registry data (65.2% response rate [933 of 1431 eligible patients]), 452 (48.4%) indicated that they would value comfort-focused care, 179 (19.2%) that they would value longevity-focused care, and 302 (32.4%) that they were unsure about the intensity of care they would value. Many had not completed an advance directive (estimated probability, 47.5% [95% CI, 42.9%-52.1%] of those who would value comfort-focused care vs 28.1% [95% CI, 24.0%-32.3%] of those who would value longevity-focused care or were unsure; P < .001), had not discussed hospice (estimated probability, 28.6% [95% CI, 24.6%-32.9%] comfort focused vs 18.2% [95% CI, 14.7%-21.7%] longevity focused or unsure; P < .001), or had not discussed stopping dialysis (estimated probability, 33.3% [95% CI, 29.0%-37.7%] comfort focused vs 21.9% [95% CI, 18.2%-25.8%] longevity focused or unsure; P < .001). Most respondents wanted to receive cardiopulmonary resuscitation (estimated probability, 78.0% [95% CI, 74.2%-81.7%] comfort focused vs 93.9% [95% CI, 91.4%-96.1%] longevity focused or unsure; P < .001) and mechanical ventilation (estimated probability, 52.0% [95% CI, 47.4%-56.6%] comfort focused vs 77.9% [95% CI, 74.0%-81.7%] longevity focused or unsure; P < .001). Among decedents, the percentages of participants who received an intensive procedure during the final month of life (estimated probability, 23.5% [95% CI, 16.5%-31.0%] comfort focused vs 26.1% [95% CI, 18.0%-34.5%] longevity focused or unsure; P = .64), discontinued dialysis (estimated probability, 38.3% [95% CI, 32.0%-44.8%] comfort focused vs 30.2% [95% CI, 23.0%-37.8%] longevity focused or unsure; P = .09), and enrolled in hospice (estimated probability, 32.2% [95% CI, 25.7%-38.7%] comfort focused vs 23.3% [95% CI, 16.4%-30.5%] longevity focused or unsure; P = .07) were not statistically different. Conclusions and Relevance This survey study found that there appeared to be a disconnect between patients' expressed values, which were largely comfort focused, and their engagement in advance care planning and end-of-life care, which reflected a focus on longevity. These findings suggest important opportunities to improve the quality of care for patients receiving dialysis.
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Affiliation(s)
| | | | | | - Yoshio N. Hall
- Department of Medicine, University of Washington, Seattle
| | | | | | | | - J. Randall Curtis
- Department of Medicine, Stanford University, Palo Alto, California
- Cambia Palliative Care Center of Excellence, Department of Medicine, University of Washington, Seattle
| | - Ann M. O’Hare
- Department of Medicine, University of Washington, Seattle
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Hu X, Yang M, Li X, Chen Y, Ouyang S, Li L. Knowledge, attitude, and practice of nephrologists on the decision for renal replacement therapy. BMC Public Health 2023; 23:654. [PMID: 37020206 PMCID: PMC10077733 DOI: 10.1186/s12889-023-15530-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 03/27/2023] [Indexed: 04/07/2023] Open
Abstract
BACKGROUND This study aimed to investigate the Knowledge, Attitude, and Practice (KAP) of nephrologists on the decision of renal replacement therapy (RRT), including peritoneal dialysis, hemodialysis, and kidney transplantation. METHODS This multicenter cross-sectional study was conducted on qualified nephrologists who volunteered to participate between July and August 2022 by using a self-administered questionnaire. RESULTS Among 327 nephrologists, the total knowledge, attitude, and practice scores were 12.03 ± 2.11/16, 58.39 ± 6.62/75, and 27.15 ± 2.74/30, respectively. Multivariate logistic regression analysis showed that the attitude score (peritoneal dialysis: OR = 1.19, 95%CI: 1.13-1.25, P < 0.001; hemodialysis: OR = 1.14, 95%CI: 1.09-1.19, P < 0.001; kidney transplantation: OR = 1.12, 95%CI: 1.07-1.16, P < 0.001), 41-50 years of age (peritoneal dialysis: OR = 0.45, 95%CI: 0.21-0,98, P = 0.045; hemodialysis: OR = 0.27, 95%CI: 0.12-0.60, P = 0.001; kidney transplantation: OR = 0.45, 95%CI:0.20-0.97, P = 0.042), and > 50 years of age (peritoneal dialysis: OR = 0.27, 95%CI: 0.08-0.84, P = 0.024; hemodialysis: OR = 0.45, 95%CI: 0.20-0.97, P = 0.042; kidney transplantation: OR = 0.24, 95%CI: 0.08-0.77, P = 0.016) were independently associated with the consideration score of peritoneal dialysis, hemodialysis, and kidney transplantation. CONCLUSION Better attitudes may lead to more consideration by nephrologists when choosing between peritoneal dialysis, hemodialysis, and kidney transplantation and relatively less consideration by senior physicians when making decisions; in addition, having good knowledge and good attitudes may lead to better practice.
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Affiliation(s)
- Xiaofang Hu
- Department of Clinical Medicine, School of Medicine, Hunan Normal University, No. 371 Tongzipo Road, Yue-Lu District, Changsha, 410013, Hunan, China
| | - Ming Yang
- Department of Nephrology, Zhuzhou Central Hospital, Zhuzhou, 412007, Hunan, China
| | - Xiangyi Li
- Department of Nephrology, Hunan Provincial People's Hospital, The First-Affiliated Hospital of Hunan Normal University, No. 61 Jie-Fang West Road, Fu-Rong District, Changsha, 410005, Hunan, China
| | - Yu Chen
- Department of Nephrology, Hunan Provincial People's Hospital, The First-Affiliated Hospital of Hunan Normal University, No. 61 Jie-Fang West Road, Fu-Rong District, Changsha, 410005, Hunan, China
| | - Shaxi Ouyang
- Department of Nephrology, Hunan Provincial People's Hospital, The First-Affiliated Hospital of Hunan Normal University, No. 61 Jie-Fang West Road, Fu-Rong District, Changsha, 410005, Hunan, China.
| | - Lin Li
- Department of Clinical Medicine, School of Medicine, Hunan Normal University, No. 371 Tongzipo Road, Yue-Lu District, Changsha, 410013, Hunan, China.
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10
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Wong SPY, Oestreich T, Prince DK, Curtis JR. A Patient Decision Aid About Conservative Kidney Management in Advanced Kidney Disease: A Randomized Pilot Trial. Am J Kidney Dis 2023:S0272-6386(23)00065-3. [PMID: 36740038 DOI: 10.1053/j.ajkd.2022.12.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 12/16/2022] [Indexed: 02/05/2023]
Abstract
RATIONALE & OBJECTIVE Available decision aids for patients about treatment of advanced chronic kidney disease (CKD) often lack information on conservative kidney management (CKM). We assessed the feasibility and acceptability of a decision aid on CKM among patients with advanced CKD and their family members. STUDY DESIGN Randomized pilot trial. SETTING & PARTICIPANTS Patients aged≥75 years with stage 4 or 5 CKD and their family members at 4 medical centers in the greater Seattle area between August 2020 and December 2021. INTERVENTIONS Usual care with or without a decision aid on CKM. OUTCOME Acceptability was assessed by attrition rates between the initial study visit (T1) and the 3-month follow-up evaluation (T3). The primary outcome and measure of feasibility was the proportion of participants who discussed CKM with a health care provider between T1 and T3. RESULTS We randomized 92 patients of whom 86 (55.8% male; age 82±6 years; 82.6% White) completed T1-42 in the usual care arm and 44 in the usual care plus decision aid arm-and 56 family members of whom 53 (18.9% male; age 71±11 years; 86.8% White) completed T1-20 in usual care arm and 33 in the usual care plus decisions aid arm. The attrition rates were 21% versus 21% (P=1.0) for patients, and 10% versus 18% (P=0.46) for family members in the usual care versus usual care plus decisions aid arms. Receipt of the decision aid significantly increased discussion of CKM with a health care provider for patients (26.4% vs 3.0%, P=0.007) and family members (26.9% vs 0, P=0.02). LIMITATIONS Possible limited generalizability because participants were a relatively homogenous group. The decision aid focuses on CKM and may be less applicable to those with limited knowledge of kidney replacement therapies. CONCLUSIONS A CKM decision aid was feasible and acceptable, and increased discussion of this treatment option with health care providers. This aid may serve as a useful adjunct to the currently available educational tools on treatments for advanced CKD. FUNDING Grant from a not-for-profit entity (National Palliative Care Research Center). TRIAL REGISTRATION Registered at ClinicalTrials.gov with study number NCT04919941.
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Affiliation(s)
- Susan P Y Wong
- Department of Medicine, University of Washington, Seattle, Washington.
| | - Taryn Oestreich
- Department of Medicine, University of Washington, Seattle, Washington
| | - David K Prince
- Department of Medicine, University of Washington, Seattle, Washington
| | - J Randall Curtis
- Department of Medicine, University of Washington, Seattle, Washington; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington
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11
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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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12
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Bursic AE, Schell JO. Hospice Care in Conservative Kidney Management. Semin Nephrol 2023; 43:151398. [PMID: 37524007 DOI: 10.1016/j.semnephrol.2023.151398] [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: 08/02/2023]
Abstract
Hospice care offers multidisciplinary expertise to optimize symptom management and quality of life for patients with limited life expectancy and help ensure that patients receive care that reflects their personal goals and values. Many patients receiving conservative kidney management (CKM) and their loved ones can benefit from the additional support that hospice provides, particularly as symptom burdens and functional status worsen over the last few months of life. We provide an overview of hospice services and how they may benefit patients receiving CKM, describe the evolution of optimal CKM strategies and collaboration between nephrology and hospice clinicians over the course of disease progression, and explore challenges to effective hospice care delivery for patients with chronic kidney disease and how to address them.
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Affiliation(s)
- Alexandra E Bursic
- Renal-Electrolyte Division, University of Pittsburgh Medical Center, Pittsburgh, PA.
| | - Jane O Schell
- Renal-Electrolyte Division, University of Pittsburgh Medical Center, Pittsburgh, PA; Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
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13
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Ladin K, Tighiouart H, Bronzi O, Koch-Weser S, Wong JB, Levine S, Agarwal A, Ren L, Degnan J, Sewall LN, Kuramitsu B, Fox P, Gordon EJ, Isakova T, Rifkin D, Rossi A, Weiner DE. Effectiveness of an Intervention to Improve Decision Making for Older Patients With Advanced Chronic Kidney Disease : A Randomized Controlled Trial. Ann Intern Med 2023; 176:29-38. [PMID: 36534976 DOI: 10.7326/m22-1543] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Older patients with advanced chronic kidney disease (CKD) face difficult decisions about managing kidney failure, frequently experiencing decisional conflict, regret, and treatment misaligned with preferences. OBJECTIVE To assess whether a decision aid about kidney replacement therapy improved decisional quality compared with usual care. DESIGN Multicenter, randomized, controlled trial. (ClinicalTrials.gov: NCT03522740). SETTING 8 outpatient nephrology clinics associated with 4 U.S. centers. PARTICIPANTS English-fluent patients, 70 years and older with nondialysis CKD stages 4 to 5 recruited from 2018 to 2020. INTERVENTION DART (Decision-Aid for Renal Therapy) is an interactive, web-based decision aid for older adults with CKD. Both groups received written education about treatments. MEASUREMENTS Change in the decisional conflict scale (DCS) score from baseline to 3, 6, 12, and 18 months. Secondary outcomes included change in prognostic and treatment knowledge and change in uncertainty. RESULTS Among 400 participants, 363 were randomly assigned: 180 to usual care, 183 to DART. Decisional quality improved with DART with mean DCS declining compared with control (mean difference, -8.5 [95% CI, -12.0 to -5.0]; P < 0.001), with similar findings at 6 months, attenuating thereafter. At 3 months, knowledge improved with DART versus usual care (mean difference, 7.2 [CI, 3.7 to 10.7]; P < 0.001); similar findings at 6 months were modestly attenuated at 18 months (mean difference, 5.9 [CI, 1.4 to 10.3]; P = 0.010). Treatment preferences changed from 58% "unsure" at baseline to 28%, 20%, 23%, and 14% at 3, 6, 12, and 18 months, respectively, with DART, versus 51% to 38%, 35%, 32%, and 18% with usual care. LIMITATION Latinx patients were underrepresented. CONCLUSION DART improved decision quality and clarified treatment preferences among older adults with advanced CKD for 6 months after the DART intervention. PRIMARY FUNDING SOURCE Patient-Centered Outcomes Research Institute (PCORI).
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Affiliation(s)
- Keren Ladin
- Research on Ethics, Aging, and Community Health (REACH Lab), Medford, and Departments of Community Health and Occupational Therapy, Tufts University, Medford, Massachusetts (K.L.)
| | - Hocine Tighiouart
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, and Tufts Clinical and Translational Science Institute, Tufts University, Boston, Massachusetts (H.T.)
| | - Olivia Bronzi
- William B. Schwartz Division of Nephrology, Tufts Medical Center, Boston, Massachusetts (O.B., D.E.W.)
| | - Susan Koch-Weser
- Department of Public Health & Community Medicine, Tufts University School of Medicine, Boston, Massachusetts (S.K.)
| | - John B Wong
- Division of Clinical Decision Making, Tufts Medical Center, Boston, Massachusetts (J.B.W.)
| | - Sarah Levine
- Cooper Medical School of Rowan University, Camden, New Jersey (S.L., A.A.)
| | - Arushi Agarwal
- Cooper Medical School of Rowan University, Camden, New Jersey (S.L., A.A.)
| | - Lucy Ren
- The University of North Texas Health Science Center at Fort Worth/Texas College of Osteopathic Medicine, Fort Worth, Texas (L.R.)
| | - Jack Degnan
- Division of Nephrology-Hypertension, UC San Diego, La Jolla, and Nephrology Section, VA San Diego Healthcare System, San Diego, California (J.D., D.R.)
| | - Lexi N Sewall
- Maine Nephrology Associates, Maine Medical Center, Portland, Maine (L.N.S.)
| | - Brianna Kuramitsu
- Division of Transplantation, Department of Surgery, Center for Health Services & Outcomes Research, and Center for Bioethics and Medical Humanities, Northwestern University Feinberg School of Medicine, Chicago, Illinois (B.K., E.J.G.)
| | - Patrick Fox
- Division of Nephrology and Hypertension, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois (P.F.)
| | - Elisa J Gordon
- Division of Transplantation, Department of Surgery, Center for Health Services & Outcomes Research, and Center for Bioethics and Medical Humanities, Northwestern University Feinberg School of Medicine, Chicago, Illinois (B.K., E.J.G.)
| | - Tamara Isakova
- Division of Nephrology and Hypertension, Department of Medicine, and Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois (T.I.)
| | - Dena Rifkin
- Division of Nephrology-Hypertension, UC San Diego, La Jolla, and Nephrology Section, VA San Diego Healthcare System, San Diego, California (J.D., D.R.)
| | - Ana Rossi
- Piedmont Transplant Institute, Atlanta, Georgia (A.R.)
| | - Daniel E Weiner
- William B. Schwartz Division of Nephrology, Tufts Medical Center, Boston, Massachusetts (O.B., D.E.W.)
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14
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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] [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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15
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Scherer JS, Rau ME, Krieger A, Xia Y, Zhong H, Brody A, Charytan DM, Chodosh J. A Pilot Randomized Controlled Trial of Integrated Palliative Care and Nephrology Care. KIDNEY360 2022; 3:1720-1729. [PMID: 36514730 PMCID: PMC9717658 DOI: 10.34067/kid.0000352022] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 08/04/2022] [Indexed: 04/12/2023]
Abstract
BACKGROUND There has been a call by both patients and health professionals for the integration of palliative care with nephrology care, yet there is little evidence describing the effect of this approach. The objective of this paper is to report the feasibility and acceptability of a pilot randomized controlled trial testing the efficacy of integrated palliative and nephrology care. METHODS English speaking patients with CKD stage 5 were randomized to monthly palliative care visits for 3 months in addition to their usual care, as compared with usual nephrology care. Feasibility of recruitment, retention, completion of intervention processes, and feedback on participation was measured. Other outcomes included differences in symptom burden change, measured by the Integrated Palliative Outcome Scale-Renal, and change in quality of life, measured by the Kidney Disease Quality of Life questionnaire and completion of advance care planning documents. RESULTS Of the 67 patients approached, 45 (67%) provided informed consent. Of these, 27 patients completed the study (60%), and 14 (74%) of those in the intervention group completed all visits. We found small improvements in overall symptom burden (-2.92 versus 1.57) and physical symptom burden scores (-1.92 versus 1.79) in the intervention group. We did not see improvements in the quality-of-life scores, with the exception of the physical component score. The intervention group completed more advance care planning documents than controls (five health care proxy forms completed versus one, nine Medical Orders for Life Sustaining Treatment forms versus none). CONCLUSIONS We found that pilot testing through a randomized controlled trial of an ambulatory integrated palliative and nephrology care clinical program was feasible and acceptable to participants. This intervention has the potential to improve the disease experience for those with nondialysis CKD and should be tested in other CKD populations with longer follow-up. CLINICAL TRIALS REGISTRY NAME AND REGISTRATION NUMBER Pilot Randomized-controlled Trial of Integrated Palliative and Nephrology Care Versus Usual Nephrology Care, NCT04520984.
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Affiliation(s)
- Jennifer S. Scherer
- Division of Geriatric Medicine and Palliative Care, Department of Internal Medicine, NYU Grossman School of Medicine, New York, New York
- Division of Nephrology, Department of Internal Medicine, NYU Grossman School of Medicine, New York, New York
| | - Megan E. Rau
- Division of Geriatric Medicine and Palliative Care, Department of Internal Medicine, NYU Grossman School of Medicine, New York, New York
| | - Anna Krieger
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
| | - Yuhe Xia
- Division of Biostatistics, Department of Population Health, NYU Grossman School of Medicine, New York, New York
| | - Hua Zhong
- Division of Biostatistics, Department of Population Health, NYU Grossman School of Medicine, New York, New York
| | - Abraham Brody
- Division of Geriatric Medicine and Palliative Care, Department of Internal Medicine, NYU Grossman School of Medicine, New York, New York
- Hartford Institute for Geriatric Nursing, NYU Rory Meyers College of Nursing, New York, New York
| | - David M. Charytan
- Division of Nephrology, Department of Internal Medicine, NYU Grossman School of Medicine, New York, New York
| | - Joshua Chodosh
- Division of Geriatric Medicine and Palliative Care, Department of Internal Medicine, NYU Grossman School of Medicine, New York, New York
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16
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Quek CWN, Ong RRS, Wong RSM, Chan SWK, Chok AKL, Shen GS, Teo AYT, Panda A, Burla N, Wong YA, Chee RCH, Loh CYL, Lee KW, Tan GHN, Leong REJ, Koh NSY, Ong YT, Chin AMC, Chiam M, Lim C, Zhou XJ, Ong SYK, Ong EK, Krishna LKR. Systematic scoping review on moral distress among physicians. BMJ Open 2022; 12:e064029. [PMID: 36691160 PMCID: PMC9442489 DOI: 10.1136/bmjopen-2022-064029] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 08/15/2022] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Concepts of moral distress (MD) among physicians have evolved and extend beyond the notion of psychological distress caused by being in a situation in which one is constrained from acting on what one knows to be right. With many accounts involving complex personal, professional, legal, ethical and moral issues, we propose a review of current understanding of MD among physicians. METHODS A systematic evidence-based approach guided systematic scoping review is proposed to map the current concepts of MD among physicians published in PubMed, Embase, PsycINFO, Web of Science, SCOPUS, ERIC and Google Scholar databases. Concurrent and independent thematic and direct content analysis (split approach) was conducted on included articles to enhance the reliability and transparency of the process. The themes and categories identified were combined using the jigsaw perspective to create domains that form the framework of the discussion that follows. RESULTS A total of 30 156 abstracts were identified, 2473 full-text articles were reviewed and 128 articles were included. The five domains identified were as follows: (1) current concepts, (2) risk factors, (3) impact, (4) tools and (5) interventions. CONCLUSIONS Initial reviews suggest that MD involves conflicts within a physician's personal beliefs, values and principles (personal constructs) caused by personal, ethical, moral, contextual, professional and sociocultural factors. How these experiences are processed and reflected on and then integrated into the physician's personal constructs impacts their self-concepts of personhood and identity and can result in MD. The ring theory of personhood facilitates an appreciation of how new experiences create dissonance and resonance within personal constructs. These insights allow the forwarding of a new broader concept of MD and a personalised approach to assessing and treating MD. While further studies are required to test these findings, they offer a personalised means of supporting a physician's MD and preventing burn-out.
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Affiliation(s)
- Chrystie Wan Ning Quek
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore
| | - Ryan Rui Song Ong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore
| | - Ruth Si Man Wong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore
| | - Sarah Wye Kit Chan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore
| | - Amanda Kay-Lyn Chok
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore
| | - Grace Shen Shen
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore
| | - Andrea York Tiang Teo
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore
| | - Aiswarya Panda
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore
| | - Neha Burla
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore
| | - Yu An Wong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore
| | - Ryan Choon Hoe Chee
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore
| | - Caitlin Yuen Ling Loh
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore
| | - Kun Woo Lee
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore
| | - Gabrielle Hui Ning Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore
| | - Ryan Emmanuel Jian Leong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore
| | - Natalie Song Yi Koh
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore
| | - Yun Ting Ong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore
| | | | - Min Chiam
- Division of Cancer Education, National Cancer Centre Singapore, Singapore
| | - Crystal Lim
- Medical Social Services, Singapore General Hospital, Singapore
| | - Xuelian Jamie Zhou
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore
- Duke-NUS Medical School, Singapore
| | - Simon Yew Kuang Ong
- Division of Cancer Education, National Cancer Centre Singapore, Singapore
- Duke-NUS Medical School, Singapore
| | - Eng Koon Ong
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore
- Duke-NUS Medical School, Singapore
| | - Lalit Kumar Radha Krishna
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore
- Division of Cancer Education, National Cancer Centre Singapore, Singapore
- Duke-NUS Medical School, Singapore
- Palliative Care Institute Liverpool, University of Liverpool, Liverpool, UK
- Centre of Biomedical Ethics, National University of Singapore, Singapore
- The Palliative Care Centre for Excellence in Research and Education, Singapore
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17
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[Comprehensive conservative care of stage 5-CKD: A practical guide]. Nephrol Ther 2022; 18:155-171. [PMID: 35732405 DOI: 10.1016/j.nephro.2022.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 04/20/2022] [Indexed: 10/17/2022]
Abstract
In French-speaking countries, the anglicism "traitement conservateur" is commonly used in clinical practice for CKD 5 patients, meaning comprehensive conservative care. In 2015, the publication of KDIGO controversies put forward this "new" therapeutic option at the same level as dialysis or transplantation. However, its detailed contents remain heterogeneous due to cultural and ethical considerations, varying with regional or national health systems. This is the reason why the French-speaking society of Nephrology, Dialysis, Transplantation (SFNDT) set up an international debate to publish clinical guidelines in French.
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18
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Wong SP, Oestreich T, Chandler B, Curtis JR. Using Human-Centered Design Principles to Create a Decision Aid on Conservative Kidney Management for Advanced Kidney Disease. KIDNEY360 2022; 3:1242-1252. [PMID: 35919540 PMCID: PMC9337892 DOI: 10.34067/kid.0000392022] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 05/04/2022] [Indexed: 01/11/2023]
Abstract
Background Most patients are unaware of approaches to treating advanced chronic kidney disease (CKD) other than dialysis. Methods We developed a dedicated decision aid on conservative kidney management using human-centered design principles in three phases: (1) discovery: engagement of informants to understand their needs and preferences; (2) design: multiple rapid cycles of ideation, prototyping, and testing of a decision aid with a small group of informants; and (3) implementation: testing the decision aid in real-world settings with attention to how the decision aid can be further refined. Informants included a national patient advisory committee on kidney diseases, 50 patients with stage 4 or 5 CKD and 35 of their family members, and 16 clinicians recruited from the greater Seattle area between June 2019 and September 2021. Results Findings from the discovery phase informed an initial prototype of the decision aid, which included five sections: a description of kidney disease and its signs and symptoms, an overview of conservative kidney management and the kinds of supports provided, self-reflection exercises to elicit patients' values and goals, the pros and cons of conservative kidney management, and the option of changing one's mind about conservative kidney management. The prototype underwent several rounds of iteration during its design phase, which resulted in the addition of an introductory section describing the intended audience and more detailed information in other sections. Findings from its implementation phase led to the addition of examples of common questions that patients and family members had about conservative kidney management and a final section on other related educational resources. Conclusions Human-centered design principles supported a systematic and collaborative approach between researchers, patients, family members, and clinicians for developing a decision aid on conservative kidney management.
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Affiliation(s)
- Susan P.Y. Wong
- VA Puget Sound Health Care System, Division of Nephrology, University of Washington, Seattle, Washington,University of Washington, School of Medicine, Division of Nephrology, Seattle, Washington
| | - Taryn Oestreich
- University of Washington, School of Medicine, Division of Nephrology, Seattle, Washington
| | - Bridgett Chandler
- University of Washington, School of Medicine, Division of Nephrology, Seattle, Washington
| | - J. Randall Curtis
- University of Washington, Division of Pulmonary, Critical Care and Sleep Medicine, Seattle, Washington
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19
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Saeed F, Moss AH, Duberstein PR, Fiscella KA. Enabling Patient Choice: The "Deciding Not to Decide" Option for Older Adults Facing Dialysis Decisions. J Am Soc Nephrol 2022; 33:880-882. [PMID: 35169067 PMCID: PMC9063883 DOI: 10.1681/asn.2021081143] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
- Fahad Saeed
- Departments of Medicine and Public Health, Divisions of Nephrology and Palliative Care, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Alvin H Moss
- Sections of Nephrology, Geriatrics, and Palliative Medicine, West Virginia University School of Medicine, Morgantown, West Virginia
| | - Paul R Duberstein
- Department of Health Behavior, Society, and Policy, Rutgers School of Public Health, Piscataway, New Jersey
| | - Kevin A Fiscella
- Department of Family Medicine and Center for Communication and Disparities Research, University of Rochester School of Medicine and Dentistry, Rochester, New York
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20
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Verberne WR, Stiggelbout AM, Bos WJW, van Delden JJM. Asking the right questions: towards a person-centered conception of shared decision-making regarding treatment of advanced chronic kidney disease in older patients. BMC Med Ethics 2022; 23:47. [PMID: 35477488 PMCID: PMC9047263 DOI: 10.1186/s12910-022-00784-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 04/18/2022] [Indexed: 12/18/2022] Open
Abstract
An increasing number of older patients have to decide on a treatment plan for advanced chronic kidney disease (CKD), involving dialysis or conservative care. Shared decision-making (SDM) is recommended as the model for decision-making in such preference-sensitive decisions. The aim of SDM is to come to decisions that are consistent with the patient’s values and preferences and made by the patient and healthcare professional working together. In clinical practice, however, SDM appears to be not yet routine and needs further implementation. A shift from a biomedical to a person-centered conception might help to make the process more shared. Shared should, therefore, be interpreted as two persons bringing two perspectives to the table, that both need to be explored during the decision-making process. Starting from the patient’s perspective will enable to determine the mutual goals of care first and, subsequently, determine the best way for achieving those goals. To perform such SDM, the healthcare professional needs to become a skilled companion, being part of the patient’s relational context, and start asking the right questions about what matters to the patient as person. In this article, we describe the need for a person-centered conception of SDM for the setting of older patients with advanced CKD.
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Affiliation(s)
- Wouter R Verberne
- Department of Internal Medicine, St Antonius Hospital, Nieuwegein, The Netherlands. .,Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands. .,Department of Internal Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
| | - Anne M Stiggelbout
- Medical Decision Making, Department of Biomedical Data Sciences, 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
| | - Johannes J M van Delden
- University Medical Center Utrecht, Julius Center for Health Sciences and Primary Care, Utrecht, The Netherlands
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21
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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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22
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Allen RJ, Saeed F. Dialysis Organization Online Information on Kidney Failure Treatments: A Content Analysis Using Corpus Linguistics. Kidney Med 2022; 4:100462. [PMID: 35620083 PMCID: PMC9127690 DOI: 10.1016/j.xkme.2022.100462] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Rationale & Objective Dialysis organizations’ websites may influence patient decision making, but the websites have received almost no consideration. We investigated how/whether these websites present all kidney replacement therapy options and how the quality of life of these options is portrayed. Study Design Content analysis using corpus linguistics (computer-assisted language analysis). Setting Website content aimed at patients from the 2 major dialysis organizations’ websites, totaling 226,968 words. The analysis took place from November 12, 2020, to March 30, 2021. Analytical Approach We used linguistic software (AntConc) to document the frequencies of words needed to present treatment options and quality of life information. Results Over both sites, dialysis mentions outstripped transplantation mentions. Organization A did not appear to reference conservative kidney management. Organization B mentioned dialysis more often than conservative management, at a ratio of 34:1. Organization A did not attribute symptoms to dialysis, whereas organization B had 12 mentions of dialysis-induced symptoms out of 87 total symptom references. Both organizations framed life on dialysis optimistically, suggesting that patients can continue to engage in “work,” “sex,” or “travel”; organization A referenced sex, work, and/or travel 123 times and organization B referenced these 262 times. Limitations We used quantitative analysis and linked ideas with certain keywords. We did not conduct a detailed qualitative inquiry. Conclusions The websites emphasized dialysis as a treatment for kidney failure, and the quality of life on dialysis was framed very optimistically. Qualitative studies of treatment modalities and the quality of life on dialysis in the patient-targeted material of dialysis organizations are needed.
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23
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Liu CK, Kurella Tamura M. Conservative Care for Kidney Failure-The Other Side of the Coin. JAMA Netw Open 2022; 5:e222252. [PMID: 35285925 DOI: 10.1001/jamanetworkopen.2022.2252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Christine K Liu
- Geriatric Research and Education Clinical Center, Veteran Affairs Palo Alto Health Care System, Palo Alto, California
- Section of Geriatrics, Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California
| | - Manjula Kurella Tamura
- Geriatric Research and Education Clinical Center, Veteran Affairs Palo Alto Health Care System, Palo Alto, California
- Division of Nephrology, Stanford University School of Medicine, Stanford, California
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24
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Wong SPY, Rubenzik T, Zelnick L, Davison SN, Louden D, Oestreich T, Jennerich AL. Long-term Outcomes Among Patients With Advanced Kidney Disease Who Forgo Maintenance Dialysis: A Systematic Review. JAMA Netw Open 2022; 5:e222255. [PMID: 35285915 PMCID: PMC9907345 DOI: 10.1001/jamanetworkopen.2022.2255] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
IMPORTANCE An understanding of the long-term outcomes of patients with advanced chronic kidney disease not treated with maintenance dialysis is needed to improve shared decision-making and care practices for this population. OBJECTIVE To evaluate survival, use of health care resources, changes in quality of life, and end-of-life care of patients with advanced kidney disease who forgo dialysis. EVIDENCE REVIEW MEDLINE, Embase (Excerpta Medica Database), and CINAHL (Cumulative Index of Nursing and Allied Health Literature) were searched from inception through December 3, 2021, for all English language longitudinal studies of adults in whom there was an explicit decision not to pursue maintenance dialysis. Two investigators independently reviewed all studies and selected those reporting survival, use of health care resources, changes in quality of life, or end-of-life care during follow-up. Studies of patients who initiated and then discontinued maintenance dialysis and patients in whom it was not clear that there was an explicit decision to forgo dialysis were excluded. One author abstracted all study data, of which 12% was independently adjudicated by a second author (<1% error rate). FINDINGS Forty-one cohort studies comprising 5102 patients (range, 11-812 patients) were included in this systematic review (5%-99% men; mean age range, 60-87 years). Substantial heterogeneity in study designs and measures used to report outcomes limited comparability across studies. Median survival of cohorts ranged from 1 to 41 months as measured from a baseline mean estimated glomerular filtration rate ranging from 7 to 19 mL/min/1.73 m2. Patients generally experienced 1 to 2 hospital admissions, 6 to 16 in-hospital days, 7 to 8 clinic visits, and 2 emergency department visits per person-year. During an observation period of 8 to 24 months, mental well-being improved, and physical well-being and overall quality of life were largely stable until late in the illness course. Among patients who died during follow-up, 20% to 76% had enrolled in hospice, 27% to 68% died in a hospital setting and 12% to 71% died at home; 57% to 76% were hospitalized, and 4% to 47% received an invasive procedure during the final month of life. CONCLUSIONS AND RELEVANCE Many patients who do not pursue dialysis survived several years and experienced sustained quality of life until late in the illness course. Nonetheless, use of acute care services was common and intensity of end-of-life care highly variable across cohorts. These findings suggest that consistent approaches to the study of conservative kidney management are needed to enhance the generalizability of findings and develop models of care that optimize outcomes among conservatively managed patients.
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Affiliation(s)
- Susan P. Y. Wong
- Health Services Research and Development Center, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Division of Nephrology, University of Washington, Seattle
| | - Tamara Rubenzik
- Divisions of Nephrology and Geriatrics, Gerontology and Palliative Care, University of California, San Diego
| | - Leila Zelnick
- Division of Nephrology, University of Washington, Seattle
| | - Sara N. Davison
- Division of Nephrology, University of Alberta, Edmonton, Canada
| | - Diana Louden
- Health Sciences Library, University of Washington, Seattle
| | - Taryn Oestreich
- Health Services Research and Development Center, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Division of Nephrology, University of Washington, Seattle
| | - Ann L. Jennerich
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle
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25
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Lupu D, Moss AH. The Role of Kidney Supportive Care and Active Medical Management Without Dialysis in Supporting Well-Being in Kidney Care. Semin Nephrol 2022; 41:580-591. [PMID: 34973702 DOI: 10.1016/j.semnephrol.2021.10.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
People living with kidney failure often experience a higher symptom burden (including anxiety and depression) and lower quality of life than patients with other serious chronic diseases. The end of life for these patients is characterized by high intensity of treatment (such as intensive care unit stays) and lack of support for family. Kidney supportive care, which emphasizes quality of life, person-centered care, and holistic care for the person and their family, is an approach that improves well-being by aligning care with the patient's preferences and goals. Kidney supportive care encompasses identifying seriously ill patients, eliciting patient values and goals through shared decision making and advance care planning, assessing and managing symptoms, communicating prognosis, offering active medical management without dialysis, and planning and managing care transitions, especially at the end of life. Models, strategies, and tools for incorporating kidney supportive care and active medical management without dialysis into existing workflows are available. However, barriers to implementation in the United States include clinician knowledge gaps, current workflows, and financial incentives, which make it difficult to break from the de facto default practice of starting dialysis for patients with kidney failure regardless of age, frailty, or debilitating condition. Policy changes are needed to fully implement kidney supportive care in the United States.
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Affiliation(s)
- Dale Lupu
- Center for Aging, Health and Humanities, George Washington University, Washington, DC.
| | - Alvin H Moss
- Center for Health Ethics and Law, West Virginia University School of Medicine, Morgantown, WV
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26
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de Jong RW, Jager KJ, Vanholder RC, Couchoud C, Murphy M, Rahmel A, Massy ZA, Stel VS. Results of the European EDITH nephrologist survey on factors influencing treatment modality choice for end-stage kidney disease. Nephrol Dial Transplant 2021; 37:126-138. [PMID: 33486525 PMCID: PMC8719583 DOI: 10.1093/ndt/gfaa342] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Access to forms of dialysis, kidney transplantation (Tx) and comprehensive conservative management (CCM) for patients with end-stage kidney disease (ESKD) varies across European countries. Attitudes of nephrologists, information provision and decision-making may influence this access and nephrologists may experience several barriers when providing treatments for ESKD. METHODS We surveyed European nephrologists and kidney transplant surgeons treating adults with ESKD about factors influencing modality choice. Descriptive statistics were used to compare the opinions of professionals from European countries with low-, middle- and high-gross domestic product purchasing power parity (GDP PPP). RESULTS In total, 681 professionals from 33 European countries participated. Respondents from all GDP categories indicated that ∼10% of patients received no information before the start of renal replacement therapy (RRT) (P = 0.106). Early information provision and more involvement of patients in decision-making were more frequently reported in middle- and high-GDP countries (P < 0.05). Professionals' attitudes towards several treatments became more positive with increasing GDP (P < 0.05). Uptake of in-centre haemodialysis was sufficient to 73% of respondents, but many wanted increased uptake of home dialysis, Tx and CCM. Respondents experienced different barriers according to availability of specific treatments in their centre. The occurrence of barriers (financial, staff shortage, lack of space/supplies and patient related) decreased with increasing GDP (P < 0.05). CONCLUSIONS Differences in factors influencing modality choice when providing RRT or CCM to adults with ESKD were found among low-, middle- and high-GDP countries in Europe. Therefore a unique pan-European policy to improve access to treatments may be inefficient. Different policies for clusters of countries could be more useful.
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Affiliation(s)
- Rianne W de Jong
- ERA-EDTA Registry, Department of Medical Informatics, Amsterdam Public
Health Research Institute, Amsterdam UMC, University of Amsterdam,
Amsterdam, The Netherlands
| | - Kitty J Jager
- ERA-EDTA Registry, Department of Medical Informatics, Amsterdam Public
Health Research Institute, Amsterdam UMC, University of Amsterdam,
Amsterdam, The Netherlands
| | - Raymond C Vanholder
- Nephrology Section, Department of Internal Medicine and Pediatrics, Ghent
University Hospital, Ghent, Belgium
- European Kidney Health Alliance (EKHA), Brussels, Belgium
| | - Cécile Couchoud
- REIN Registry, Agence de la Biomédecine, Saint-Denis La
Plaine, France
| | - Mark Murphy
- The Irish Kidney Association CLG, Dublin, Ireland
| | - Axel Rahmel
- Deutsche Stiftung Organtransplantation, Frankfurt am Main,
Germany
| | - Ziad A Massy
- INSERM U1018, Équipe 5, Centre de Recherche en Epidémiologie et Santé des
Populations (CESP), Université Paris Saclay et Université Versailles Saint Quentin en
Yvelines (UVSQ), Villejuif, France
- Service de Néphrologie et Dialyse, Assistance Publique—Hopitaux de Paris
(APHP), Hôpital Universitaire Ambroise Paré, Boulogne-Billancourt,
France
| | - Vianda S Stel
- ERA-EDTA Registry, Department of Medical Informatics, Amsterdam Public
Health Research Institute, Amsterdam UMC, University of Amsterdam,
Amsterdam, The Netherlands
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27
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Ladin K, Porteny T, Perugini JM, Gonzales KM, Aufort KE, Levine SK, Wong JB, Isakova T, Rifkin D, Gordon EJ, Rossi A, Koch-Weser S, Weiner DE. Perceptions of Telehealth vs In-Person Visits Among Older Adults With Advanced Kidney Disease, Care Partners, and Clinicians. JAMA Netw Open 2021; 4:e2137193. [PMID: 34870680 PMCID: PMC8649833 DOI: 10.1001/jamanetworkopen.2021.37193] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 10/04/2021] [Indexed: 12/11/2022] Open
Abstract
Importance Telehealth has been posited as a cost-effective means for improving access to care for persons with chronic conditions, including kidney disease. Perceptions of telehealth among older patients with chronic illness, their care partners, and clinicians are largely unknown but are critical to successful telehealth use and expansion efforts. Objective To identify patient, care partner, and nephrologists' perceptions of the patient-centeredness, benefits, drawbacks of telehealth compared to in-person visits. Design, Setting, and Participants This qualitative study used semistructured interviews conducted from August to December 2020 with purposively sampled patients (aged 70 years or older, chronic kidney disease stages 4 to 5), care partners, and clinicians in Boston, Massachusetts; Chicago, Illinois; Portland, Maine; and San Diego, California. Main Outcomes and Measures Participants described telehealth experiences, including factors contributing to and impeding engagement, satisfaction, and quality of care. Thematic analysis was used to analyze data. Results Of 60 interviews, 19 (32%) were with clinicians, 30 (50%) with patients, and 11 (18%) with care partners; 16 clinicians (84%) were nephrologists; 17 patient participants (43%) were non-Hispanic Black, and 38 (67%) were women. Four overarching themes characterized telehealth's benefits and drawbacks for patient-centered care among older, chronically ill adults: inconsistent quality of care, patient experience and engagement, loss of connection and mistrust (eg, challenges discussing bad news), and disparities with accessing telehealth. Although telehealth improved convenience and care partner engagement, participants expressed concerns about clinical effectiveness and limitations of virtual physical examinations and potentially widening disparities in access. Many participants shared concerns about harms to the patient-clinician relationship, limited ability to comfort patients in virtual settings, and reduced patient trust. Conclusions and Relevance Older patients, care partners, and kidney clinicians (ie, nephrologists and physician assistants) shared divergent views of patient-centered telehealth care, especially its clinical effectiveness, patient experience, access to care, and clinician-patient relationship. Understanding older patients' and kidney clinicians' perceptions of telehealth elucidate barriers that should be addressed to promote high-quality care and telehealth use.
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Affiliation(s)
- Keren Ladin
- Research on Ethics, Aging, and Community Health (REACH Lab), Medford, Massachusetts
- Departments of Occupational Therapy and Community Health, Tufts University, Medford, Massachusetts
| | - Thalia Porteny
- Research on Ethics, Aging, and Community Health (REACH Lab), Medford, Massachusetts
- Departments of Occupational Therapy and Community Health, Tufts University, Medford, Massachusetts
| | - Julia M. Perugini
- Research on Ethics, Aging, and Community Health (REACH Lab), Medford, Massachusetts
| | - Kristina M. Gonzales
- Research on Ethics, Aging, and Community Health (REACH Lab), Medford, Massachusetts
- Departments of Occupational Therapy and Community Health, Tufts University, Medford, Massachusetts
| | - Kate E. Aufort
- Research on Ethics, Aging, and Community Health (REACH Lab), Medford, Massachusetts
- Departments of Occupational Therapy and Community Health, Tufts University, Medford, Massachusetts
| | - Sarah K. Levine
- William B. Schwartz MD Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | - John B. Wong
- Department of Medicine, Tufts Medical Center, Boston, Massachusetts
| | - Tamara Isakova
- Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Dena Rifkin
- Division of Nephrology, Veterans’ Affairs Healthcare System, San Diego, California
- University of California, San Diego
| | - Elisa J. Gordon
- Department of Surgery-Division of Transplantation, and Center for Health Services and Outcomes Research, and Center for Bioethics and Humanities, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Ana Rossi
- Piedmont Transplant Institute, Atlanta, Georgia
| | - Susan Koch-Weser
- Department of Public Health & Community Medicine, Tufts University School of Medicine, Massachusetts
| | - Daniel E. Weiner
- William B. Schwartz MD Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
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28
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Noyes J, Roberts G, Williams G, Chess J, Mc Laughlin L. Understanding the low take-up of home-based dialysis through a shared decision-making lens: a qualitative study. BMJ Open 2021; 11:e053937. [PMID: 34845074 PMCID: PMC8634024 DOI: 10.1136/bmjopen-2021-053937] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Accepted: 10/21/2021] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES To explore how people with chronic kidney disease who are pre-dialysis, family members and healthcare professionals together navigate common shared decision-making processes and to assess how this impacts future treatment choice. DESIGN Coproductive qualitative study, underpinned by the Making Good Decisions in Collaboration shared decision-model. Semistructured interviews with a purposive sample from February 2019 - January 2020. Interview data were analysed using framework analysis. Coproduction of logic models/roadmaps and recommendations. SETTING Five Welsh kidney services. PARTICIPANTS 95 participants (37 patients, 19 family members and 39 professionals); 44 people supported coproduction (18 patients, 8 family members and 18 professionals). FINDINGS Shared decision-making was too generic and clinically focused and had little impact on people getting onto home dialysis. Preferences of where, when and how to implement shared decision-making varied widely. Apathy experienced by patients, caused by lack of symptoms, denial, social circumstances and health systems issues made future treatment discussions difficult. Families had unmet and unrecognised needs, which significantly influenced patient decisions. Protocols containing treatment hierarchies and standards were understood by professionals but not translated for patients and families. Variation in dialysis treatment was discussed to match individual lifestyles. Patients and professionals were, however, defaulting to the perceived simplest option. It was easy for patients to opt for hospital-based treatments by listing important but easily modifiable factors. CONCLUSIONS Shared decision-making processes need to be individually tailored with more attention on patients who could choose a home therapy but select a different option. There are critical points in the decision-making process where changes could benefit patients. Patients need to be better educated and their preconceived ideas and misconceptions gently challenged. Healthcare professionals need to update their knowledge in order to provide the best advice and guidance. There needs to be more awareness of the costs and benefits of the various treatment options when making decisions.
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Affiliation(s)
- Jane Noyes
- School of Medical and Health Sciences, Bangor University, Bangor, UK
| | - Gareth Roberts
- Department of Nephrology, Cardiff and Vale University Health Board, Cardiff, UK
| | | | - James Chess
- Renal Unit, Swansea Bay University Health Board, Port Talbot, UK
| | - Leah Mc Laughlin
- School of Medical and Health Sciences, Bangor University, Bangor, UK
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29
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O Riordan J, Kane PM, Noble H, Smyth A. Advance care planning and health literacy in older dialysis patients: qualitative interview study. BMJ Support Palliat Care 2021:bmjspcare-2021-003273. [PMID: 34782344 DOI: 10.1136/bmjspcare-2021-003273] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 10/25/2021] [Indexed: 11/03/2022]
Abstract
OBJECTIVES Low health literacy among older adults is associated with limited engagement in end-of-life care planning, higher hospitalisation rates and increased mortality. Frequently, older dialysis patients derive no survival benefit from dialysis and their quality of life often deteriorates further on dialysis. Older dialysis patients' values and wishes are frequently unknown during key healthcare decision making and many endure medically intensive end-of-life scenarios. The objectives of this study were to explore older dialysis patients' understanding of haemodialysis, to explore their engagement in end-of-life care planning and to explore their satisfaction with life on haemodialysis. METHODS 15 older dialysis patients participated in qualitative semistructured interviews in two haemodialysis units in Ireland. Thematic saturation was reached. Thematic analysis, applied inductively, was used to distill the data. RESULTS Themes identified included disempowerment among participants reflected limited health literacy, poor advance care planning compromised participant well-being, haemodialysis compromised participants' core values. CONCLUSION Health literacy levels among older dialysis patients are poor, patient empowerment is limited and their participation in shared decision making and advance care planning is suboptimal. Consequently, healthcare decision making, including haemodialysis, may jeopardise patients' core values. Improving health literacy through enhanced patient education and improved communication skills training for clinicians is necessary to promote patient participation in shared decision making. Clinician training to facilitate discussion of patients' values and wishes will help guide clinicians and patients towards healthcare decisions most concordant with patients' core values. This approach will optimise the circumstances for patient-centred care.
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Affiliation(s)
- Julien O Riordan
- Palliative Medicine, IPU, Galway Hospice Foundation, Renmore, Ireland
- School of Medicine, National University of Ireland Galway School of Medicine, Galway, Ireland
| | - P M Kane
- Community Palliative Care Services, Laois, Longford, Westmeath, Mullingar General Hospital, Mullingar, Ireland
- Palliative Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Helen Noble
- School of Nursing and Midwifery, Queen's University Belfast, Belfast, UK
| | - Andrew Smyth
- Clinical Research Facility, National University of Ireland Galway, Galway, Ireland
- Nephrology, Galway University Hospitals, Galway, Ireland
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30
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Barrett TM, Davenport CA, Ephraim PL, Peskoe S, Mohottige D, DePasquale N, McElroy L, Boulware LE. Disparities in Discussions about Kidney Replacement Therapy in CKD Care. KIDNEY360 2021; 3:158-163. [PMID: 35368562 PMCID: PMC8967603 DOI: 10.34067/kid.0004752021] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 10/22/2021] [Indexed: 01/10/2023]
Abstract
Participants who identified as female and Black reported more thorough discussions of dialysis than transplant.Participants with low incomes and education reported more thorough discussions of dialysis than transplant.
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Affiliation(s)
- Tyler M. Barrett
- Division of General Internal Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Clemontina A. Davenport
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina
| | - Patti L. Ephraim
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland,Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Sarah Peskoe
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina
| | - Dinushika Mohottige
- Division of General Internal Medicine, Duke University School of Medicine, Durham, North Carolina,Division of Nephrology, Duke University School of Medicine, Durham, North Carolina
| | - Nicole DePasquale
- Division of General Internal Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Lisa McElroy
- Division of General Internal Medicine, Duke University School of Medicine, Durham, North Carolina,Division of Abdominal Transplant, Duke University School of Medicine, Durham, North Carolina
| | - L. Ebony Boulware
- Division of General Internal Medicine, Duke University School of Medicine, Durham, North Carolina
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31
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House TR, Wightman A, Rosenberg AR, Sayre G, Abdel-Kader K, Wong SPY. Challenges to Shared Decision Making About Treatment of Advanced CKD: A Qualitative Study of Patients and Clinicians. Am J Kidney Dis 2021; 79:657-666.e1. [PMID: 34673161 PMCID: PMC9016096 DOI: 10.1053/j.ajkd.2021.08.021] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 08/25/2021] [Indexed: 11/11/2022]
Abstract
RATIONALE AND OBJECTIVE Greater understanding of the challenges to shared decision-making about treatment of advanced CKD is needed to support implementation of shared decision-making in clinical practice. STUDY DESIGN Qualitative study. SETTING AND PARTICIPANTS Patients aged ≥65 years with advanced CKD and their clinicians recruited from 3 medical centers participated in semi-structured interviews. In-depth review of patients' electronic medical records was also performed. ANALYTICAL APPROACH Interview transcripts and medical record notes were analyzed using inductive thematic analysis. RESULTS Twenty-nine patients (age 73±6 years, 66% male, 59% Caucasian) and 10 of their clinicians (age 52±12 years, 30% male, 70% Caucasian) participated in interviews. Four themes emerged from qualitative analysis: 1) Competing priorities - patients and their clinicians tended to differ on when to prioritize CKD and dialysis planning above other personal or medical problems; 2) Focusing on present or future -patients were more focused on living well now while clinicians were more focused on preparing for dialysis and future adverse events; 3) Standardized versus individualized approach to CKD - although clinicians tried to personalize care recommendations to their patients, patients perceived their clinicians as taking a monolithic approach to CKD that was predicated on clinical practice guidelines and medical literature rather than patients' lived experiences with CKD and personal values and goals; and 4) Power dynamics - while patients described cautiously navigating a power differential in their therapeutic relationship with their clinicians, clinicians seemed less attuned to these power dynamics. LIMITATIONS Thematic saturation was based on patient interviews. Themes presented might incompletely reflect clinicians' perspectives. CONCLUSIONS Efforts to improve shared decision-making for treatment of advanced CKD will likely need to explicitly address differences in approaches to decision-making about treatment of advanced CKD between patients and their clinicians and perceived power imbalances in the therapeutic relationship.
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Affiliation(s)
- Taylor R House
- Pediatric Nephrology Fellow, Department of Pediatrics, University of Washington, Seattle Children's Hospital, 4800 Sandpoint Way NE, O.C. 9.820, Seattle, WA 98105.
| | - Aaron Wightman
- Associate Professor, Department of Pediatrics, University of Washington, Seattle Children's Hospital
| | - Abby R Rosenberg
- Associate Professor, Department of Pediatrics, University of Washington
| | - George Sayre
- Clinical Assistant Professor, Department of Health Services, University of Washington, HSR&D Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System
| | | | - Susan P Y Wong
- Assistant Professor of Medicine, University of Washington, VA Puget Sound Health Care System
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32
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O Riordan J, Kane PM, Noble H, Smyth A. Advance care planning in older dialysis patients: health care literacy qualitative study. BMJ Support Palliat Care 2021:bmjspcare-2021-003398. [PMID: 34635544 DOI: 10.1136/bmjspcare-2021-003398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 09/28/2021] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Low health literacy among older adults is associated with limited engagement in end-of-life care plans, more hospitalisations and excess mortality. Frequently, older patients derive no survival benefit from dialysis and quality of life often deteriorates with dialysis. Older dialysis patients' values and wishes are often unknown during key healthcare decision-making and many endure medically intensive end-of-life interventions . The objectives of this study were to examine older dialysis patients' understanding of haemodialysis, their engagement in end-of-life care planning and their satisfaction with life on haemodialysis. METHODS 15 older dialysis patients participated in qualitative semi-structured interviews in two haemodialysis units . Thematic saturation was reached. Thematic analysis, applied inductively, distilled the data. RESULTS Themes identified included disempowerment which reflected limited health literacy, poor advance care planning compromised well-being and haemodialysis compromised their core values. CONCLUSION Health literacy among older dialysis patients appeared poor, patient empowerment was limited and participation in shared decision-making and advance care planning suboptimal. Consequently, complex healthcare decision-making, including haemodialysis may jeopardise patients' core values. These findings have significant implications for the validity of the informed consent process prior to dialysis initiation. Improved health literacy through enhanced patient education and better communication skills for clinicians are necessary to promote patient participation in shared decision-making. Clinician training to facilitate discussion of patients' values and wishes will help guide clinicians and patients towards healthcare decisions most concordant with individual core values. This will optimise patient-centred care.
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Affiliation(s)
- Julien O Riordan
- Palliative Medicine, IPU, Galway Hospice Foundation, Renmore, Ireland
- School of Medicine, National University of Ireland Galway, Galway, Ireland
| | - P M Kane
- Community Palliative Care Services, Palliative Medicine, Specialist Community Palliative Care Services, Laois, Ireland
- Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Helen Noble
- Queen's University Belfast School of Nursing and Midwifery, Belfast, UK
| | - Andrew Smyth
- Clinical Research Facility, National University of Ireland Galway, Galway, Ireland
- Nephrology, Galway University Hospital, Galway, Ireland
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Saeed F, Shah AY, Allen RJ, Epstein RM, Fiscella KA. Communication principles and practices for making shared decisions about renal replacement therapy: a review of the literature. Curr Opin Nephrol Hypertens 2021; 30:507-515. [PMID: 34148978 PMCID: PMC8373782 DOI: 10.1097/mnh.0000000000000731] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW To provide an overview of the skill set required for communication and person-centered decision making for renal replacement therapy (RRT) choices, especially conservative kidney management (CKM). RECENT FINDINGS Research on communication and decision-making skills for shared RRT decision making is still in infancy. We adapt literature from other fields such as primary care and oncology for effective RRT decision making. SUMMARY We review seven key skills: (1) Announcing the need for decision making (2) Agenda Setting (3) Educating patients about RRT options (4) Discussing prognoses (5) Eliciting patient preferences (6) Responding to emotions and showing empathy, and (7) Investing in the end. We also provide example sentences to frame the conversations around RRT choices including CKM.
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Affiliation(s)
- Fahad Saeed
- Departments of Medicine and Public Health, Division of Nephrology
- Division of Palliative Care
- University of Rochester School of Medicine, National University of Medical Sciences
| | - Amna Yousaf Shah
- Rawalpindi, Pakistan; CITE Center, Department of Behavioral and Natural Sciences
| | | | - Ronald M Epstein
- Division of Palliative Care
- Department of Family Medicine and Center for Center for Communication and Disparities Research, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Kevin A Fiscella
- Department of Family Medicine and Center for Center for Communication and Disparities Research, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
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Foxwell AM, H Meghani S, M Ulrich C. Clinician distress in seriously ill patient care: A dimensional analysis. Nurs Ethics 2021; 29:72-93. [PMID: 34427135 DOI: 10.1177/09697330211003259] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Caring for patients with serious illness may severely strain clinicians causing distress and probable poor patient outcomes. Unfortunately, clinician distress and its impact historically has received little attention. RESEARCH PURPOSE The purpose of this article was to investigate the nature of clinician distress. RESEARCH DESIGN Qualitative inductive dimensional analysis. PARTICIPANTS AND RESEARCH CONTEXT After review of 577 articles from health sciences databases, a total of 33 articles were eligible for analysis. ETHICAL CONSIDERATIONS This study did not require ethical review and the authors adhered to appropriate academic standards in their analysis. FINDINGS A narrative of clinician distress in the hospital clinician in the United States emerged from the analysis. This included clinicians' perceptions and sense of should or the feeling that something is awry in the clinical situation. The explanatory matrix consequence of clinician distress occurred under conditions including: the recognition of conflict, the recognition of emotion, or the recognition of a mismatch; followed by a process of an inability to feel and act according to one's values due to a precipitating event. DISCUSSION This study adds three unique contributions to the concept of clinician distress by (1) including the emotional aspects of caring for seriously ill patients, (2) providing a new framework for understanding clinician distress within the clinician's own perceptions, and (3) looking at action outside of a purely moral lens by dimensionalizing data, thereby pulling apart what has been socially constructed. CONCLUSION For clinicians, learning to recognize one's perceptions and emotional reactions is the first step in mitigating distress. There is a critical need to understand the full scope of clinician distress and its impact on the quality of patient-centered care in serious illness.
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Affiliation(s)
- Anessa M Foxwell
- 6572University of Pennsylvania School of Nursing, Philadelphia, USA; Perlman Center for Advanced Medicine, Philadelphia, USA
| | | | - Connie M Ulrich
- 6572University of Pennsylvania School of Nursing, Philadelphia, USA; Leonard Davis Institute for Health Economics, USA
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Schlögl M, Pak ES, Bansal AD, Schell JO, Ganai S, Kamal AH, Swetz KM, Maguire JM, Perrakis A, Warraich HJ, Jones CA. Top Ten Tips Palliative Care Clinicians Should Know About Prognostication in Critical Illness and Heart, Kidney, and Liver Diseases. J Palliat Med 2021; 24:1561-1567. [PMID: 34283924 DOI: 10.1089/jpm.2021.0330] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Specialty palliative care (PC) clinicians are frequently asked to discuss prognosis with patients and their families. When conveying information about prognosis, PC clinicians need also to discuss the likelihood of prolonged hospitalization, cognitive and functional disabilities, and death. As PC moves further and further upstream, it is crucial that PC providers have a broad understanding of curative and palliative treatments for serious diseases and can collaborate in prognostication with specialists. In this article, we present 10 tips for PC clinicians to consider when caring and discussing prognosis for the seriously ill patients along with their caregivers and care teams. This is the second in a three-part series around prognostication in adult and pediatric PC.
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Affiliation(s)
- Mathias Schlögl
- Centre on Aging and Mobility, University Hospital Zurich and City Hospital Waid Zurich, Zurich, Switzerland.,University Clinic for Acute Geriatric Care, City Hospital Waid Zurich, Zurich, Switzerland
| | - Esther S Pak
- Advanced Heart Failure/Transplantation, Philadelphia VA Medical Center, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Amar D Bansal
- Section of Palliative Care and Medical Ethics, Department of General Medicine, Pittsburgh, Pennsylvania, USA.,Division of Renal-Electrolyte, University of Pittsburgh School of Medicine, UPMC Health System, Pittsburgh, Pennsylvania, USA
| | - Jane O Schell
- Section of Palliative Care and Medical Ethics, Department of General Medicine, Pittsburgh, Pennsylvania, USA.,Division of Renal-Electrolyte, University of Pittsburgh School of Medicine, UPMC Health System, Pittsburgh, Pennsylvania, USA
| | - Sabha Ganai
- Department of Surgery, University of North Dakota School of Medicine and Health Sciences, Fargo, North Dakota, USA
| | - Arif H Kamal
- Duke Cancer Institute, Duke University, Durham, North Carolina, USA.,Duke Fuqua School of Business, Duke University, Durham, North Carolina, USA
| | - Keith M Swetz
- Center for Palliative and Supportive Care, Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA.,Department of Medicine, Division of Gerontology, Geriatrics and Palliative Care, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jennifer M Maguire
- Division of Pulmonary and Critical Care Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Aristotelis Perrakis
- Department of General, Visceral, Vascular and Transplant Surgery, University Hospital Magdeburg, Magdeburg, Germany
| | - Haider J Warraich
- Department of Medicine, Brigham and Women's Hospital and Veterans Affairs Boston Healthcare System, Harvard Medical School, Boston, Massachusetts, USA
| | - Christopher A Jones
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
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Ernecoff NC, Abdel-Kader K, Cai M, Yabes J, Shah N, Schell JO, Jhamb M. Implementation of Surprise Question Assessments using the Electronic Health Record in Older Adults with Advanced CKD. KIDNEY360 2021; 2:966-973. [PMID: 35373084 PMCID: PMC8791363 DOI: 10.34067/kid.0007062020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 04/01/2021] [Indexed: 12/12/2022]
Abstract
Background The Surprise Question (SQ; "Would you be surprised if this patient died in the next 12 months?") is a validated prognostication tool for mortality and hospitalization among patients with advanced CKD. Barriers in clinical workflows have slowed SQ implementation in practice. Objectives The aims of this study were: (1) to evaluate implementation outcomes after the use of electronic health record (EHR) decision support to automate the collection of the SQ; and (2) to assess the prognostic utility of the SQ for mortality and hospitalization/emergency room (ER) visits. Methods We developed and implemented a best practice alert (BPA) in the EHR to identify nephrology outpatients ≥60 years of age with an eGFR <30 ml/min per 1.73 m2. At appointment, the BPA prompted the physician to answer the SQ. We assessed the rate and timeliness of provider responses. We conducted a post-hoc open-ended survey to assess physician perceptions of SQ implementation. We assessed the SQ's prognostic utility in survival and time-to-hospital encounter (hospitalization/ER visit) analyses. Results Among 510 patients for whom the BPA triggered, 95 (19%) had the SQ completed by 16 physicians. Among those completed, nearly all (98%) were on appointment day, and 61 (64%) the first time the BPA fired. Providers answered "no" for 27 (28%) and "yes" for 68 (72%) patients. By 12 months, six (22%) "no" patients died; three (4%) "yes" patients died (hazard ratio [HR] 2.86, ref: yes, 95% CI, 1.06 to 7.69). About 35% of "no" patients and 32% of "yes" patients had a hospital encounter by 12 months (HR, 1.85, ref: yes, 95% CI, 0.93 to 3.69). Physicians noted (1) they had goals-of-care conversations unprompted; (2) EHR-based interventions alone for goals-of-care are ineffective; and (3) more robust engagement is necessary. Conclusions We successfully integrated the SQ into the EHR to aid in clinical practice. Additional implementation efforts are needed to encourage further integration of the SQ in clinical practice.
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Affiliation(s)
- Natalie C. Ernecoff
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Khaled Abdel-Kader
- Division of Nephrology and Hypertension, Vanderbilt University, Nashville, Tennessee
| | - Manqi Cai
- Department of Biostatistics, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jonathan Yabes
- Department of Biostatistics, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Nirav Shah
- Division of Renal and Electrolyte, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jane O. Schell
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Division of Renal and Electrolyte, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Manisha Jhamb
- Division of Renal and Electrolyte, University of Pittsburgh, Pittsburgh, Pennsylvania
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Cohen RA, Bursic A, Chan E, Norman MK, Arnold RM, Schell JO. NephroTalk Multimodal Conservative Care Curriculum for Nephrology Fellows. Clin J Am Soc Nephrol 2021; 16:972-979. [PMID: 33579742 PMCID: PMC8216616 DOI: 10.2215/cjn.11770720] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Conservative care, a comprehensive treatment path for advanced kidney disease most suitable for individuals unlikely to benefit from dialysis, is underutilized in the United States. One reason is an absence of robust education about this approach and how to discuss it with potential candidates. To address this need, we developed a multimodal conservative care curriculum for nephrology fellows. This curriculum consists of four online modules that address essential concepts and communication skills related to conservative care. It is followed by an in-person, interactive, "flipped classroom" session facilitated by designated nephrology educators at participating Accreditation Council for Graduate Medical Education nephrology training programs. Curriculum effect was assessed using surveys completed by participating fellows immediately before and following the curriculum and for participating nephrology educators following flipped classroom teaching; 148 nephrology trainees from 19 programs participated, with 108 completing both pre- and postcurriculum surveys. Mean self-reported preparedness (measured on a five-point Likert scale) increased significantly for all ten concepts taught in the curriculum. The mean correct score on eight knowledge questions increased from 69% to 82% following the curriculum (P<0.001). Fellows rated the curriculum highly and reported that they plan to practice skills learned. For the 19 nephrology program educators, the mean perceived preparedness to teach all curriculum domains increased after, compared with before, facilitating the flipped classroom, reaching significance for seven of the ten concepts measured. Data suggest that fellows' participation in a multimodal curriculum increased knowledge and preparation for fundamental conservative care concepts and communication skills. Fellows rated the curriculum highly. Educator participation appears to have increased preparedness for teaching the curriculum concepts, making it likely that future education in conservative care will become more widespread. Herein, we describe the curriculum content, which we have made publicly available in order to encourage broader implementation, and its effect on participating fellows and the nephrology educators who facilitated it.
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Affiliation(s)
- Robert A. Cohen
- Nephrology Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Alexandra Bursic
- Internal Medicine, Department of Medicine, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Emily Chan
- Internal Medicine, Department of Medicine, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Marie K. Norman
- Department of Medicine, Institute for Clinical Research Education, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Robert M. Arnold
- Section of Palliative Care and Medical Ethics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Jane O. Schell
- Section of Palliative Care and Medical Ethics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania,Renal-Electrolyte Division, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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de Jong RW, Stel VS, Heaf JG, Murphy M, Massy ZA, Jager KJ. Non-medical barriers reported by nephrologists when providing renal replacement therapy or comprehensive conservative management to end-stage kidney disease patients: a systematic review. Nephrol Dial Transplant 2021; 36:848-862. [PMID: 31898742 PMCID: PMC8075372 DOI: 10.1093/ndt/gfz271] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 10/31/2019] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Large international differences exist in access to renal replacement therapy (RRT) modalities and comprehensive conservative management (CCM) for patients with end-stage kidney disease (ESKD), suggesting that some patients are not receiving the most appropriate treatment. Previous studies mainly focused on barriers reported by patients or medical barriers (e.g. comorbidities) reported by nephrologists. An overview of the non-medical barriers reported by nephrologists when providing the most appropriate form of RRT (other than conventional in-centre haemodialysis) or CCM is lacking. METHODS We searched in EMBASE and PubMed for original articles with a cross-sectional design (surveys, interviews or focus groups) published between January 2010 and September 2018. We included studies in which nephrologists reported barriers when providing RRT or CCM to adult patients with ESKD. We used the barriers and facilitators survey by Peters et al. [Ruimte Voor Verandering? Knelpunten en Mogelijkheden Voor Verbeteringen in de Patiëntenzorg. Nijmegen: Afdeling Kwaliteit van zorg (WOK), 2003] as preliminary framework to create our own model and performed meta-ethnographic analysis of non-medical barriers in text, tables and figures. RESULTS Of the 5973 articles screened, 16 articles were included using surveys (n = 10), interviews (n = 5) and focus groups (n = 1). We categorized the barriers into three levels: patient level (e.g. attitude, role perception, motivation, knowledge and socio-cultural background), level of the healthcare professional (e.g. fears and concerns, working style, communication skills) and level of the healthcare system (e.g. financial barriers, supportive staff and practice organization). CONCLUSIONS Our systematic review has identified a number of modifiable, non-medical barriers that could be targeted by, for example, education and optimizing financing structure to improve access to RRT modalities and CCM.
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Affiliation(s)
- Rianne W de Jong
- ERA-EDTA Registry, Department of Medical Informatics, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Vianda S Stel
- ERA-EDTA Registry, Department of Medical Informatics, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - James G Heaf
- Department of Medicine, Zealand University Hospital, Roskilde, Denmark
| | - Mark Murphy
- The Irish Kidney Association CLG, Dublin, Ireland
| | - Ziad A Massy
- Division of Nephrology, Ambroise Paré University Hospital, APHP, University of Paris Ouest-Versailles-St-Quentin-en-Yvelines (UVSQ), Boulogne-Billancourt/Paris, France
- Institut National de la Santé et de la Recherche Médicale (INSERM) U1018, Team 5, CESP UVSQ, University Paris Saclav, Villejuif, France
| | - Kitty J Jager
- ERA-EDTA Registry, Department of Medical Informatics, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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Metzger M, Yoder J, Fitzgibbon K, Blackhall L, Abdel-Rahman E. Nephrology and Palliative Care Collaboration in the Care of Patients With Advanced Kidney Disease: Results of a Clinician Survey. Kidney Med 2021; 3:368-377.e1. [PMID: 34136783 PMCID: PMC8178464 DOI: 10.1016/j.xkme.2021.01.008] [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] [Indexed: 11/16/2022] Open
Abstract
Rationale & Objective Despite calls for integrating palliative care into chronic kidney disease (CKD) care, uptake remains low. The study aim was to describe clinicians’ perceptions of the clinical and research priorities in CKD care and the main barriers to collaboration. Study Design This was a descriptive cross-sectional study using an online survey developed by clinicians and researchers as the primary data collection method. Setting & Participants Clinicians in nephrology and palliative care departments (N = 195) at an academic health center in Virginia were invited to participate. Of the 48.7% (n = 95) who responded, most were registered nurses (65.3%) in nephrology (80%) with more than 15 years’ experience (40%). Predictors Factors including discipline (nursing, social work, and physician) and practice area (palliative care or nephrology) were assessed. Outcomes Main outcomes of interest included clinicians’ perceptions of the role of palliative care, barriers to collaboration, and the top clinical and research priorities for patients with advanced CKD. Analytic Approach Survey data were analyzed using SPSS using descriptive statistics. Results Respondents reported being comfortable caring for patients near the end of life and endorsed advance care planning and collaboration between nephrology and palliative care teams. However, both rarely happen. Fragmentation, or poor coordination of care, was perceived to be the main barrier to collaboration. Perceptions regarding collaboration facilitation differed; nephrology clinicians identified patient/family education as the most important facilitator while palliative care clinicians identified clinician education as most important. Top clinical priorities differed. Palliative care clinicians reported pain/symptom management as taking priority while nephrology clinicians identified caregiver/family support. Developing interventions to support treatment-related decision making was the top research priority. Limitations Results reflect perceptions of about half the clinicians at 1 academic health center. Conclusions Additional studies to capture patients’ and families’ perspectives and examine end-of-life care processes are needed. Results may inform future targeted interventions.
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Affiliation(s)
- Maureen Metzger
- University of Virginia School of Nursing, Charlottesville, VA
| | - Jonathan Yoder
- University of Virginia School of Nursing, Charlottesville, VA
| | - Kara Fitzgibbon
- Hemodialysis Unit and Home Hemodialysis Program, University of Virginia Health, University of Virginia School of Medicine, Charlottesville, VA
| | - Leslie Blackhall
- Weldon Cooper Center, Center for Survey Research, University of Virginia, Charlottesville, VA
| | - Emaad Abdel-Rahman
- Palliative Care Services, University of Virginia Health, University of Virginia School of Medicine, Charlottesville, VA
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Moss AH, Navia RO. Should we recommend dialysis for older patients with kidney failure and dementia? J Am Geriatr Soc 2021; 69:1105-1107. [PMID: 33666942 DOI: 10.1111/jgs.17076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 02/06/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Alvin H Moss
- Section of Nephrology, West Virginia University School of Medicine, Morgantown, West Virginia, USA.,Section of Geriatrics and Palliative Medicine, West Virginia University School of Medicine, Morgantown, West Virginia, USA
| | - R Osvaldo Navia
- Section of Geriatrics and Palliative Medicine, West Virginia University School of Medicine, Morgantown, West Virginia, USA
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Nair D, Malhotra S, Lupu D, Harbert G, Scherer JS. Challenges in communication, prognostication and dialysis decision-making in the COVID-19 pandemic: implications for interdisciplinary care during crisis settings. Curr Opin Nephrol Hypertens 2021; 30:190-197. [PMID: 33395035 PMCID: PMC7855398 DOI: 10.1097/mnh.0000000000000689] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW Using case vignettes, we highlight challenges in communication, prognostication, and medical decision-making that have been exacerbated by the coronavirus disease-19 (COVID-19) pandemic for patients with kidney disease. We include best practice recommendations to mitigate these issues and conclude with implications for interdisciplinary models of care in crisis settings. RECENT FINDINGS Certain biomarkers, demographics, and medical comorbidities predict an increased risk for mortality among patients with COVID-19 and kidney disease, but concerns related to physical exposure and conservation of personal protective equipment have exacerbated existing barriers to empathic communication and value clarification for these patients. Variability in patient characteristics and outcomes has made prognostication nuanced and challenging. The pandemic has also highlighted the complexities of dialysis decision-making for older adults at risk for poor outcomes related to COVID-19. SUMMARY The COVID-19 pandemic underscores the need for nephrologists to be competent in serious illness communication skills that include virtual and remote modalities, to be aware of prognostic tools, and to be willing to engage with interdisciplinary teams of palliative care subspecialists, intensivists, and ethicists to facilitate goal-concordant care during crisis settings.
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Affiliation(s)
- Devika Nair
- Vanderbilt University Medical Center, Division of Nephrology and Hypertension
- Vanderbilt O’Brien Center for Kidney Disease, Nashville, Tennessee
| | - Sonia Malhotra
- Tulane University Deming Department of General Internal Medicine and Geriatrics/University Medical Center New Orleans Palliative Medicine and Supportive Care, New Orleans, Louisiana
| | - Dale Lupu
- The George Washington University School of Nursing, Washington, District of Columbia
| | - Glenda Harbert
- The George Washington University School of Nursing, Washington, District of Columbia
| | - Jennifer S. Scherer
- New York University Grossman School of Medicine, Division of Geriatrics and Palliative Care
- New York University Grossman School of Medicine, Division of Nephrology, New York, New York, USA
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St Clair Russell J, Oliverio A, Paulus A. Barriers to Conservative Management Conversations: Perceptions of Nephrologists and Fellows-in-Training. J Palliat Med 2021; 24:1497-1504. [PMID: 33601978 DOI: 10.1089/jpm.2020.0690] [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] [Indexed: 11/12/2022] Open
Abstract
Background: Not all treatments are appropriate for all individuals with kidney failure (KF). Studies suggest that conversations surrounding end-of-life decisions occur too late or not at all. Objectives: The aim of this research was to identify perceived barriers to such discussions among nephrologists and nephrology fellows to determine if barriers differ by experience level. Design: Phase I consisted of semistructured telephone interviews with nephrologists and fellows. Phase II included focus groups with nominal group technique in which providers ranked barriers to discussions about not initiating/withholding dialysis (NIWD) or discontinuing dialysis (DD). Setting/Subjects: U.S. community-based nephrologists and nephrology fellows. Results: Seven interviews were conducted with each group (n = 14) in phase I. Many barriers cited were similar among providers, however, differences were related to fellows' position as trainees citing the "reaction of their attending/supervising physician or other providers" as a barrier to NIWD and "lacking their attending physician's support" as a barrier to DD. Six focus groups were conducted, nephrologists (n = 22) and fellows (n = 18), in phase II. The highest ranked barrier to NIWD for nephrologists was "discordant opinions among patient and family"; fellows ranked "time to hold conversation" highest. Nephrologists' highest barrier to DD was the "finality of the decision (death)"; fellows ranked the "inertia of the clinical encounter" highest. Conclusions: Capturing the perspectives of nephrologists and fellows concerning the barriers to conservative management of patients with KF may inform the development of targeted education/training interventions by experience level focused on communication skills, conflict resolution, and negotiation.
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Affiliation(s)
| | - Andrea Oliverio
- Department of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Amber Paulus
- Quality Insights, Charleston, West Virginia, USA
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van der Borg WE, Verdonk P, de Jong-Camerik J, Abma TA. How to relate to dialysis patients' fatigue - perspectives of dialysis nurses and renal health professionals: A qualitative study. Int J Nurs Stud 2021; 117:103884. [PMID: 33631400 DOI: 10.1016/j.ijnurstu.2021.103884] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 01/14/2021] [Accepted: 01/16/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Although fatigue among the dialysis population is known as a severe and debilitating health problem, this symptom is often under recognized and undertreated. OBJECTIVE This qualitative study aimed to gain a better understanding of how dialysis nurses and renal health professionals perceive and address dialysis patient's fatigue in renal care practice. DESIGN We conducted a qualitative descriptive study to explore how nurses and renal health professionals perceive and address dialysis patients' fatigue in their daily health care practices. A constructivist grounded theory approach guided analysis and conceptualisation of findings. SETTING(S) This study took place at 13 academic and regional settings across the Netherlands. The study was approved by the Medical Ethics Committee (2015.049), on behalf of VU University medical center in Amsterdam. PARTICIPANTS Twenty-one renal health professionals of various disciplines took part in interviews: ten dialysis nurses, four nephrologists, two physician assistants, five medical social workers. METHODS Semi-structured interviews were conducted in order to gain in-depth insight into the perspectives of dialysis nurses and renal health professionals. An inductive thematic analysis provided insight into health professionals' stances toward dialysis patients' fatigue in light of their daily care context and practices. RESULTS Two main themes emerged; 1) 'Fatigue in the background': Shows there is strong focus on medical-technical aspects of the disease. All health professionals perceive fatigue as an intangible symptom that is difficult to address, and falls outside their scope of responsibility and competence. Communication about fatigue among professionals and with patients is limited, pushing fatigue further into the background. 2) 'Vulnerabilities in the background': Especially nurses and social workers signal the accumulating vulnerabilities of dialysis patients and associate these with fatigue (old age, multimorbidities, financial and social problems). Although the need for psychological support is acknowledged, multiple vulnerabilities increase the complexity and intensity of care, and further strengthens the medical-technical focus of care and treatment. CONCLUSIONS There is a need to enable renal health professionals to communicate about the complex nature of fatigue in renal patients and stimulate interdisciplinary exchange and shared responsibility. Dialysis nurses have frequent contact with patients during dialysis treatment and are the first to notice when patients' fatigue increases and their overall condition deteriorates. They can play an important role to go beyond the technological imperative of care and understand the lived experiences of patients within their social contexts.
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Affiliation(s)
- Wieke E van der Borg
- Amsterdam UMC, location VUmc, Department of Ethics, Law and Humanities, Amsterdam, the Netherlands.
| | - Petra Verdonk
- Amsterdam UMC, location VUmc, Department of Ethics, Law and Humanities, Amsterdam, the Netherlands
| | - Judith de Jong-Camerik
- Amsterdam UMC, location VUmc, Department of Ethics, Law and Humanities, Amsterdam, the Netherlands
| | - Tineke A Abma
- Amsterdam UMC, location VUmc, Department of Ethics, Law and Humanities, Amsterdam, the Netherlands
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44
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Bristol AA, Chaudhry S, Assis D, Wright R, Moriyama D, Harwood K, Brody AA, Charytan DM, Chodosh J, Scherer JS. An Exploratory Qualitative Study of Patient and Caregiver Perspectives of Ambulatory Kidney Palliative Care. Am J Hosp Palliat Care 2021; 38:1242-1249. [PMID: 33438435 DOI: 10.1177/1049909120986121] [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] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVES The ideal clinical model to deliver palliative care to patients with advanced kidney disease is currently unknown. Internationally, ambulatory kidney palliative care clinics have emerged with positive outcomes, yet there is limited data from the United States (US). In this exploratory study we report perceptions of a US-based ambulatory kidney palliative care clinic from the perspective of patient and caregiver attendees. The objective of this study was to inform further improvement of our clinical program. METHODS Semi-structured interviews were conducted to elicit the patient and caregiver experience. Eleven interviews (8 patients with chronic kidney disease stage IV or V and 3 caregivers) were analyzed using qualitative description design. RESULTS We identified 2 themes: "Communication addressing the emotional and physical aspects of disease" and "Filling gaps in care"; Subthemes include perceived value in symptom management, assistance with coping with disease, engagement in advance care planning, program satisfaction and patient activation. SIGNIFICANCE OF RESULTS Qualitative analysis showed that attendees of an ambulatory kidney palliative care clinic found the clinic enhanced the management of their kidney disease and provided services that filled current gaps in their care. Shared experiences highlight the significant challenges of life with kidney disease and the possible benefits of palliative care for this population. Further study to determine the optimal model of care for kidney palliative care is needed. Inclusion of the patient and caregiver perspective will be essential in this development.
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Affiliation(s)
- Alycia A Bristol
- 16177University of Utah College of Nursing, Salt Lake City, UT, USA
| | | | - Dana Assis
- 1940Yale New Haven Health, New Haven, CT, USA
| | | | - Derek Moriyama
- 12223Keck School of Medicine of University of Southern California, CA, USA
| | - Katherine Harwood
- Columbia University-Morgan Stanley Children's Hospital, New York, NY, USA
| | - Abraham A Brody
- Hartford Institute for Geriatric Nursing, NYU Rory Meyers College of Nursing, New York, NY, USA.,Division of Geriatrics and Palliative Care, Department of Internal Medicine, NYU School of Medicine, New York, NY, USA
| | - David M Charytan
- Division of Nephrology, Department of Internal Medicine, NYU School of Medicine, New York, NY, USA
| | - Joshua Chodosh
- Division of Geriatrics and Palliative Care, Department of Internal Medicine, NYU School of Medicine, New York, NY, USA
| | - Jennifer S Scherer
- Division of Geriatrics and Palliative Care, Department of Internal Medicine, NYU School of Medicine, New York, NY, USA.,Division of Nephrology, Department of Internal Medicine, NYU School of Medicine, New York, NY, USA
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Lunney M, Bello AK, Levin A, Tam-Tham H, Thomas C, Osman MA, Ye F, Bellorin-Font E, Benghanem Gharbi M, Ghnaimat M, Htay H, Cho Y, Jha V, Ossareh S, Rondeau E, Sola L, Tchokhonelidze I, Tesar V, Tungsanga K, Kazancioglu RT, Wang AYM, Yang CW, Zemchenkov A, Zhao MH, Jager KJ, Jindal KK, Okpechi IG, Brown EA, Brown M, Tonelli M, Harris DC, Johnson DW, Caskey FJ, Davison SN. Availability, Accessibility, and Quality of Conservative Kidney Management Worldwide. Clin J Am Soc Nephrol 2021; 16:79-87. [PMID: 33323461 PMCID: PMC7792657 DOI: 10.2215/cjn.09070620] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 10/28/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND OBJECTIVES People with kidney failure typically receive KRT in the form of dialysis or transplantation. However, studies have suggested that not all patients with kidney failure are best suited for KRT. Additionally, KRT is costly and not always accessible in resource-restricted settings. Conservative kidney management is an alternate kidney failure therapy that focuses on symptom management, psychologic health, spiritual care, and family and social support. Despite the importance of conservative kidney management in kidney failure care, several barriers exist that affect its uptake and quality. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS The Global Kidney Health Atlas is an ongoing initiative of the International Society of Nephrology that aims to monitor and evaluate the status of global kidney care worldwide. This study reports on findings from the 2018 Global Kidney Health Atlas survey, specifically addressing the availability, accessibility, and quality of conservative kidney management. RESULTS Respondents from 160 countries completed the survey, and 154 answered questions pertaining to conservative kidney management. Of these, 124 (81%) stated that conservative kidney management was available. Accessibility was low worldwide, particularly in low-income countries. Less than half of countries utilized multidisciplinary teams (46%); utilized shared decision making (32%); or provided psychologic, cultural, or spiritual support (36%). One-quarter provided relevant health care providers with training on conservative kidney management delivery. CONCLUSIONS Overall, conservative kidney management is available in most countries; however, it is not optimally accessible or of the highest quality.
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Affiliation(s)
- Meaghan Lunney
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Aminu K. Bello
- Division of Nephrology and Immunology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Adeera Levin
- Division of Nephrology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Helen Tam-Tham
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Chandra Thomas
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Mohamed A. Osman
- Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Feng Ye
- Division of Nephrology and Immunology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | | | - Mohammed Benghanem Gharbi
- Urinary Tract Diseases Department, Faculty of Medicine and Pharmacy of Casablanca, University Hassan II of Casablanca, Casablanca, Morocco
| | - Mohammad Ghnaimat
- Nephrology Division, Department of Internal Medicine, The Specialty Hospital, Amman, Jordan
| | - Htay Htay
- Department of Renal Medicine, Singapore General Hospital, Singapore
| | - Yeoungjee Cho
- Australasian Kidney Trials Network, University of Queensland, Brisbane, Queensland, Australia,Translational Research Institute, Brisbane, Queensland, Australia,Metro South Integrated Nephrology and Transplant Services, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Vivekanand Jha
- George Institute for Global Health, University of New South Wales, New Delhi, India,Department of Epidemiology and Biostatistics, School of Public Health, Imperial College, London, United Kingdom,Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Shahrzad Ossareh
- Division of Nephrology, Department of Medicine, Hasheminejad Kidney Center, Iran University of Medical Sciences, Tehran, Iran
| | - Eric Rondeau
- Intensive Care Nephrology and Transplantation Department, Hopital Tenon, Assistance Publique-Hopitaux de Paris, Paris, France,Intensive Care Nephrology and Transplantation Department, Hopital Tenon, Assistance Publique-Hopitaux de Paris, Paris, France and Sorbonne Université, Paris, France
| | - Laura Sola
- Dialysis Unit, Centro de Asistencia del Sindicato Médico del Uruguay - Institución de Asistencia Medica Privada de Profesionales (CASMU-IAMPP), Montevideo, Uruguay
| | - Irma Tchokhonelidze
- Nephrology Development Clinical Center, Tbilisi State Medical University, Tbilisi, Georgia
| | - Vladimir Tesar
- Department of Nephrology, General University Hospital, Charles University, Prague, Czech Republic
| | - Kriang Tungsanga
- Department of Medicine, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Chulalongkorn University, Bangkok, Thailand,Division of Nephrology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; Bhumirajanagarindra Kidney Institute, Bangkok, Thailand
| | | | - Angela Yee-Moon Wang
- Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong Special Administrative Region, China
| | - Chih-Wei Yang
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Linkou, Taiwan,Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Alexander Zemchenkov
- Department of Internal Diseases, Clinical Pharmacology, and Nephrology, North-Western State Medical University named after I. I. Mechnikov, St. Petersburg, Russia,Department of Nephrology and Dialysis, Pavlov First St. Petersburg State Medical University, St. Petersburg, Russia
| | - Ming-hui Zhao
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China,Key Lab of Renal Disease, Ministry of Health of China, Beijing, China,Key Lab of Chronic Kidney Disease Prevention and Treatment, Ministry of Education of China, Beijing, China,Peking-Tsinghua Center for Life Sciences, Beijing, China
| | - Kitty J. Jager
- European Renal Association – European Dialysis and Transplant Association (ERA-EDTA) Registry, Department of Medical Informatics, Academic Medical Center, Amsterdam Public Health Research Institute, University of Amsterdam, Amsterdam, The Netherlands
| | - Kailash K. Jindal
- Division of Nephrology and Immunology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Ikechi G. Okpechi
- Division of Nephrology and Hypertension, University of Cape Town, Cape Town, South Africa,Kidney and Hypertension Research Unit, University of Cape Town, Cape Town, South Africa
| | - Edwina A. Brown
- Imperial College Renal and Transplant Centre, Hammersmith Hospital, London, England
| | - Mark Brown
- Department of Renal Medicine, St George Hospital and University of New South Wales, Sydney, New South Wales, Australia
| | - Marcello Tonelli
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada,Pan-American Health Organization/World Health Organization’s Collaborating Centre in Prevention and Control of Chronic Kidney Disease, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - David C. Harris
- Centre for Transplantation and Renal Research, Westmead Institute for Medical Research, University of Sydney, Sydney, New South Wales, Australia
| | - David W. Johnson
- Australasian Kidney Trials Network, University of Queensland, Brisbane, Queensland, Australia,Translational Research Institute, Brisbane, Queensland, Australia,Metro South Integrated Nephrology and Transplant Services, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Fergus J. Caskey
- UK Renal Registry, Learning and Research, Southmead Hospital, Bristol, United Kingdom and Population Health Sciences, University of Bristol, Bristol, United Kingdom,Richard Bright Renal Unit, Southmead Hospital, North Bristol National Health Service Trust, Bristol, United Kingdom
| | - Sara N. Davison
- Division of Nephrology and Immunology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
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Sprangers B, Van der Veen A, Hamaker ME, Rostoft S, Latcha S, Lichtman SM, de Moor B, Wildiers H. Initiation and termination of dialysis in older patients with advanced cancer: providing guidance in a complicated situation. THE LANCET. HEALTHY LONGEVITY 2021; 2:e42-e52. [DOI: 10.1016/s2666-7568(20)30060-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 11/09/2020] [Accepted: 11/23/2020] [Indexed: 01/19/2023] Open
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Corradi-Perini C, Beltrão JR, Ribeiro URVDCO. Circumstances Related to Moral Distress in Palliative Care: An Integrative Review. Am J Hosp Palliat Care 2020; 38:1391-1397. [PMID: 33280390 DOI: 10.1177/1049909120978826] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The practice of palliative care is involved with ethical conflicts related to the life-death process and relief of suffering. The inability to act in the face of such dilemmas, due to internal or external barriers, can cause moral distress in the healthcare professionals. OBJECTIVE The purpose of this integrative review is to analyze which circumstances cause moral distress in healthcare professionals who work in palliative care. METHODS An integrative review of the literature was made in the SCIELO and PubMed databases, based on the descriptors "palliative care" and "moral distress." Articles published between 2015-2020, in Portuguese, Spanish and English were included, following the PRISMA criteria. RESULTS From a selection of 97 documents, 56 were completed reviewed and 23 studies were included in the review. Most articles refer to the nursing area, followed by multidisciplinary studies. The circumstances related to moral distress were identified involving: personal aspects; patients and caregivers; team; environment and organization. Communication problems, lack of resources and witnessing professionals giving false hope to patient and family members were the events related to moral distress most mentioned by the articles in the review. Recommendations for reducing and preventing moral distress include empowerment and educational programs in bioethics and palliative care. CONCLUSIONS Moral distress is an evident phenomenon in palliative care, involving different situations that can impact on quality-of-care provided as well as the well-being of the healthcare professionals.
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Affiliation(s)
- Carla Corradi-Perini
- Graduated Program in Bioethics, School of Life Sciences, 28100Pontifícia Universidade Católica do Paraná, Rua Imaculada Conceição, Curitiba, Brazil
| | - Julianna Rodrigues Beltrão
- Graduated Program in Bioethics, School of Life Sciences, 28100Pontifícia Universidade Católica do Paraná, Rua Imaculada Conceição, Curitiba, Brazil
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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] [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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Oestreich T, Sayre G, O'Hare AM, Curtis JR, Wong SPY. Perspectives on Conservative Care in Advanced Kidney Disease: A Qualitative Study of US Patients and Family Members. Am J Kidney Dis 2020; 77:355-364.e1. [PMID: 33010356 PMCID: PMC8148987 DOI: 10.1053/j.ajkd.2020.07.026] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 07/25/2020] [Indexed: 11/15/2022]
Abstract
Rationale & Objective: Little is known about perceptions of conservative care among patients with advanced kidney disease in the United States. Study Design: Qualitative study using cognitive interviewing about attitudes regarding conservative care using decision aids on treatments for advanced kidney disease developed outside the United States. Setting & Participants: 14 patients 75 years or older with advanced kidney disease, defined as estimated glomerular filtration rate ≤ 20 mL/min/1.73 m2 and not receiving maintenance dialysis, and 6 of their family members. Analytical Approach: Thematic analysis of participants’ reactions to descriptions of conservative care taken from various clinical care decision aids. Results: Participants were mostly White (n = 15) and had at least some college education (n = 16). Four themes emerged from analysis of interviews: (1) core elements of conservative care: aspects of conservative care that were appealing to participants included a whole-person, team-based, and structured approach to care that focused on symptom management, maintaining current lifestyle, and managing health setbacks; (2) importance of how conservative care is framed: participants were more receptive to conservative care when this was framed as an active rather than passive treatment approach and were receptive to statements of uncertainty about future course of illness and prognosis; (3) an explicit approach to shared decision making: participants believed decisions about conservative care and dialysis should address considerations about risk and benefits of treatment options, family and clinician perspectives, and patients’ goals, values, and preferences; and (4) relationship between conservative care and dialysis: although conservative care models outside the United States are generally intended to serve as an alternative to dialysis, participants’ comments implied that they did not see conservative care and dialysis as mutually exclusive. Limitations: Themes identified may not generalize to the broader population of US patients with advanced kidney disease and their family members. Conclusions: Participants were favorably disposed to a whole-person multidisciplinary approach to conservative care, especially when framed as an active treatment approach. Models of conservative care excluding the possibility of dialysis were less embraced, suggesting that current models will require adaptation to meet the needs of US patients and their families. Conservative care is an important therapeutic option for patients with advanced kidney disease who believe that the burdens of dialysis are not outweighed by its potential benefits. However, efforts in this country to develop conservative options for patients who wish to pursue dialysis have lagged considerably behind those in other countries. In this study, we interviewed older patients with advanced kidney disease but not receiving maintenance dialysis and their family members about their reactions to descriptions of conservative care taken from decision aids developed in other countries. The findings suggest how models of conservative care developed in other countries could be adapted to meet the needs and preferences of US patients and their family members.
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Affiliation(s)
- Taryn Oestreich
- University of Washington, Seattle, WA; Health Services Research and Development Center, VA Puget Sound Health Care System, Seattle, WA
| | - George Sayre
- University of Washington, Seattle, WA; Health Services Research and Development Center, VA Puget Sound Health Care System, Seattle, WA
| | - Ann M O'Hare
- University of Washington, Seattle, WA; Health Services Research and Development Center, VA Puget Sound Health Care System, Seattle, WA
| | - J Randall Curtis
- University of Washington, Seattle, WA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA
| | - Susan P Y Wong
- University of Washington, Seattle, WA; Health Services Research and Development Center, VA Puget Sound Health Care System, Seattle, WA.
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50
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Jassal SV, Larkina M, Jager KJ, Murtagh FEM, O'Hare AM, Hanafusa N, Morgenstern H, Port FK, McCullough K, Pisoni R, Tentori F, Perlman R, Swartz RD. International variation in dialysis discontinuation in patients with advanced kidney disease. CMAJ 2020; 192:E995-E1002. [PMID: 32868271 DOI: 10.1503/cmaj.191631] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/16/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Decisions about dialysis for advanced kidney disease are often strongly shaped by sociocultural and system-level factors rather than the priorities and values of individual patients. We examined international variation in the uptake of conservative approaches to the care of patients with advanced kidney disease, in particular discontinuation of dialysis. METHODS We employed an observational cohort study design using data collected from patients maintained on long-term hemodialysis between 1996 and 2015 in facilities across 12 developed countries participating in the Dialysis Outcomes and Practice Patterns Study (DOPPS). The main outcome was discontinuation of dialysis therapy. We analyzed the association between several patient characteristics and time to dialysis discontinuation by country and phase of study entry. RESULTS A total of 259 343 DOPPS patients contributed data to the study, of whom 48 519 (18.7%) died during the study period. Of the decedents, 5808 (12.0%) discontinued dialysis before death. Rates of discontinuation were higher within the first few months after initiation of dialysis, among older adults, among those with a greater number of comorbidities and among those living in an institution. After adjustment for age, sex, dialysis duration, diabetes and dialysis era, rates of discontinuation were highest in Canada, the United States and Australia/New Zealand (33.8, 31.4 and 21.5 per 1000/yr, respectively) and lowest in Japan and Italy (< 0.1 per 1000/yr). Crude discontinuation rates were highest in dialysis facilities that were more likely to offer comprehensive conservative renal care to older adults. INTERPRETATION We found persistent international variation in average rates of dialysis discontinuation not explained by differences in patient case-mix. These differences may reflect physician-, facility- and society-level differences in clinical practice. There may be opportunities for international cross-collaboration to improve support for patients with end-stage renal disease who prefer a more conservative approach.
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Affiliation(s)
- Sarbjit V Jassal
- University Health Network (Jassal), Toronto, Ont.; Arbor Research Collaborative for Health (Larkina, Port, McCullough, Pisoni), Ann Arbor, Mich.; ERA-EDTA Registry (Jager), Department of Medical Informatics, Academic Medical Centre, Amsterdam Public Health Research Institute, University of Amsterdam, Amsterdam, Netherlands; Wolfson Palliative Care Research Centre (Murtagh), Hull York Medical School, University of Hull, Hull, UK; VA Puget Sound Health Care System (O'Hare), Seattle, Wash.; Department of Blood Purification (Hanafusa), Tokyo Women's Medical University, Tokyo, Japan; Departments of Epidemiology (Morgenstern) and Environmental Health Sciences (Morgenstern), School of Public Health, and Department of Urology (Morgenstern), Medical School, University of Michigan, Ann Arbor, Mich.; DaVita Outcomes Research and Patient Empowerment (Tentori), Denver, Colo.; Divisions of Nephrology (Perlman, Swartz) and Palliative Care (Swartz), Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Mich.
| | - Maria Larkina
- University Health Network (Jassal), Toronto, Ont.; Arbor Research Collaborative for Health (Larkina, Port, McCullough, Pisoni), Ann Arbor, Mich.; ERA-EDTA Registry (Jager), Department of Medical Informatics, Academic Medical Centre, Amsterdam Public Health Research Institute, University of Amsterdam, Amsterdam, Netherlands; Wolfson Palliative Care Research Centre (Murtagh), Hull York Medical School, University of Hull, Hull, UK; VA Puget Sound Health Care System (O'Hare), Seattle, Wash.; Department of Blood Purification (Hanafusa), Tokyo Women's Medical University, Tokyo, Japan; Departments of Epidemiology (Morgenstern) and Environmental Health Sciences (Morgenstern), School of Public Health, and Department of Urology (Morgenstern), Medical School, University of Michigan, Ann Arbor, Mich.; DaVita Outcomes Research and Patient Empowerment (Tentori), Denver, Colo.; Divisions of Nephrology (Perlman, Swartz) and Palliative Care (Swartz), Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Mich
| | - Kitty J Jager
- University Health Network (Jassal), Toronto, Ont.; Arbor Research Collaborative for Health (Larkina, Port, McCullough, Pisoni), Ann Arbor, Mich.; ERA-EDTA Registry (Jager), Department of Medical Informatics, Academic Medical Centre, Amsterdam Public Health Research Institute, University of Amsterdam, Amsterdam, Netherlands; Wolfson Palliative Care Research Centre (Murtagh), Hull York Medical School, University of Hull, Hull, UK; VA Puget Sound Health Care System (O'Hare), Seattle, Wash.; Department of Blood Purification (Hanafusa), Tokyo Women's Medical University, Tokyo, Japan; Departments of Epidemiology (Morgenstern) and Environmental Health Sciences (Morgenstern), School of Public Health, and Department of Urology (Morgenstern), Medical School, University of Michigan, Ann Arbor, Mich.; DaVita Outcomes Research and Patient Empowerment (Tentori), Denver, Colo.; Divisions of Nephrology (Perlman, Swartz) and Palliative Care (Swartz), Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Mich
| | - Fliss E M Murtagh
- University Health Network (Jassal), Toronto, Ont.; Arbor Research Collaborative for Health (Larkina, Port, McCullough, Pisoni), Ann Arbor, Mich.; ERA-EDTA Registry (Jager), Department of Medical Informatics, Academic Medical Centre, Amsterdam Public Health Research Institute, University of Amsterdam, Amsterdam, Netherlands; Wolfson Palliative Care Research Centre (Murtagh), Hull York Medical School, University of Hull, Hull, UK; VA Puget Sound Health Care System (O'Hare), Seattle, Wash.; Department of Blood Purification (Hanafusa), Tokyo Women's Medical University, Tokyo, Japan; Departments of Epidemiology (Morgenstern) and Environmental Health Sciences (Morgenstern), School of Public Health, and Department of Urology (Morgenstern), Medical School, University of Michigan, Ann Arbor, Mich.; DaVita Outcomes Research and Patient Empowerment (Tentori), Denver, Colo.; Divisions of Nephrology (Perlman, Swartz) and Palliative Care (Swartz), Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Mich
| | - Ann M O'Hare
- University Health Network (Jassal), Toronto, Ont.; Arbor Research Collaborative for Health (Larkina, Port, McCullough, Pisoni), Ann Arbor, Mich.; ERA-EDTA Registry (Jager), Department of Medical Informatics, Academic Medical Centre, Amsterdam Public Health Research Institute, University of Amsterdam, Amsterdam, Netherlands; Wolfson Palliative Care Research Centre (Murtagh), Hull York Medical School, University of Hull, Hull, UK; VA Puget Sound Health Care System (O'Hare), Seattle, Wash.; Department of Blood Purification (Hanafusa), Tokyo Women's Medical University, Tokyo, Japan; Departments of Epidemiology (Morgenstern) and Environmental Health Sciences (Morgenstern), School of Public Health, and Department of Urology (Morgenstern), Medical School, University of Michigan, Ann Arbor, Mich.; DaVita Outcomes Research and Patient Empowerment (Tentori), Denver, Colo.; Divisions of Nephrology (Perlman, Swartz) and Palliative Care (Swartz), Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Mich
| | - Norio Hanafusa
- University Health Network (Jassal), Toronto, Ont.; Arbor Research Collaborative for Health (Larkina, Port, McCullough, Pisoni), Ann Arbor, Mich.; ERA-EDTA Registry (Jager), Department of Medical Informatics, Academic Medical Centre, Amsterdam Public Health Research Institute, University of Amsterdam, Amsterdam, Netherlands; Wolfson Palliative Care Research Centre (Murtagh), Hull York Medical School, University of Hull, Hull, UK; VA Puget Sound Health Care System (O'Hare), Seattle, Wash.; Department of Blood Purification (Hanafusa), Tokyo Women's Medical University, Tokyo, Japan; Departments of Epidemiology (Morgenstern) and Environmental Health Sciences (Morgenstern), School of Public Health, and Department of Urology (Morgenstern), Medical School, University of Michigan, Ann Arbor, Mich.; DaVita Outcomes Research and Patient Empowerment (Tentori), Denver, Colo.; Divisions of Nephrology (Perlman, Swartz) and Palliative Care (Swartz), Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Mich
| | - Hal Morgenstern
- University Health Network (Jassal), Toronto, Ont.; Arbor Research Collaborative for Health (Larkina, Port, McCullough, Pisoni), Ann Arbor, Mich.; ERA-EDTA Registry (Jager), Department of Medical Informatics, Academic Medical Centre, Amsterdam Public Health Research Institute, University of Amsterdam, Amsterdam, Netherlands; Wolfson Palliative Care Research Centre (Murtagh), Hull York Medical School, University of Hull, Hull, UK; VA Puget Sound Health Care System (O'Hare), Seattle, Wash.; Department of Blood Purification (Hanafusa), Tokyo Women's Medical University, Tokyo, Japan; Departments of Epidemiology (Morgenstern) and Environmental Health Sciences (Morgenstern), School of Public Health, and Department of Urology (Morgenstern), Medical School, University of Michigan, Ann Arbor, Mich.; DaVita Outcomes Research and Patient Empowerment (Tentori), Denver, Colo.; Divisions of Nephrology (Perlman, Swartz) and Palliative Care (Swartz), Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Mich
| | - Friedrich K Port
- University Health Network (Jassal), Toronto, Ont.; Arbor Research Collaborative for Health (Larkina, Port, McCullough, Pisoni), Ann Arbor, Mich.; ERA-EDTA Registry (Jager), Department of Medical Informatics, Academic Medical Centre, Amsterdam Public Health Research Institute, University of Amsterdam, Amsterdam, Netherlands; Wolfson Palliative Care Research Centre (Murtagh), Hull York Medical School, University of Hull, Hull, UK; VA Puget Sound Health Care System (O'Hare), Seattle, Wash.; Department of Blood Purification (Hanafusa), Tokyo Women's Medical University, Tokyo, Japan; Departments of Epidemiology (Morgenstern) and Environmental Health Sciences (Morgenstern), School of Public Health, and Department of Urology (Morgenstern), Medical School, University of Michigan, Ann Arbor, Mich.; DaVita Outcomes Research and Patient Empowerment (Tentori), Denver, Colo.; Divisions of Nephrology (Perlman, Swartz) and Palliative Care (Swartz), Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Mich
| | - Keith McCullough
- University Health Network (Jassal), Toronto, Ont.; Arbor Research Collaborative for Health (Larkina, Port, McCullough, Pisoni), Ann Arbor, Mich.; ERA-EDTA Registry (Jager), Department of Medical Informatics, Academic Medical Centre, Amsterdam Public Health Research Institute, University of Amsterdam, Amsterdam, Netherlands; Wolfson Palliative Care Research Centre (Murtagh), Hull York Medical School, University of Hull, Hull, UK; VA Puget Sound Health Care System (O'Hare), Seattle, Wash.; Department of Blood Purification (Hanafusa), Tokyo Women's Medical University, Tokyo, Japan; Departments of Epidemiology (Morgenstern) and Environmental Health Sciences (Morgenstern), School of Public Health, and Department of Urology (Morgenstern), Medical School, University of Michigan, Ann Arbor, Mich.; DaVita Outcomes Research and Patient Empowerment (Tentori), Denver, Colo.; Divisions of Nephrology (Perlman, Swartz) and Palliative Care (Swartz), Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Mich
| | - Ronald Pisoni
- University Health Network (Jassal), Toronto, Ont.; Arbor Research Collaborative for Health (Larkina, Port, McCullough, Pisoni), Ann Arbor, Mich.; ERA-EDTA Registry (Jager), Department of Medical Informatics, Academic Medical Centre, Amsterdam Public Health Research Institute, University of Amsterdam, Amsterdam, Netherlands; Wolfson Palliative Care Research Centre (Murtagh), Hull York Medical School, University of Hull, Hull, UK; VA Puget Sound Health Care System (O'Hare), Seattle, Wash.; Department of Blood Purification (Hanafusa), Tokyo Women's Medical University, Tokyo, Japan; Departments of Epidemiology (Morgenstern) and Environmental Health Sciences (Morgenstern), School of Public Health, and Department of Urology (Morgenstern), Medical School, University of Michigan, Ann Arbor, Mich.; DaVita Outcomes Research and Patient Empowerment (Tentori), Denver, Colo.; Divisions of Nephrology (Perlman, Swartz) and Palliative Care (Swartz), Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Mich
| | - Francesca Tentori
- University Health Network (Jassal), Toronto, Ont.; Arbor Research Collaborative for Health (Larkina, Port, McCullough, Pisoni), Ann Arbor, Mich.; ERA-EDTA Registry (Jager), Department of Medical Informatics, Academic Medical Centre, Amsterdam Public Health Research Institute, University of Amsterdam, Amsterdam, Netherlands; Wolfson Palliative Care Research Centre (Murtagh), Hull York Medical School, University of Hull, Hull, UK; VA Puget Sound Health Care System (O'Hare), Seattle, Wash.; Department of Blood Purification (Hanafusa), Tokyo Women's Medical University, Tokyo, Japan; Departments of Epidemiology (Morgenstern) and Environmental Health Sciences (Morgenstern), School of Public Health, and Department of Urology (Morgenstern), Medical School, University of Michigan, Ann Arbor, Mich.; DaVita Outcomes Research and Patient Empowerment (Tentori), Denver, Colo.; Divisions of Nephrology (Perlman, Swartz) and Palliative Care (Swartz), Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Mich
| | - Rachel Perlman
- University Health Network (Jassal), Toronto, Ont.; Arbor Research Collaborative for Health (Larkina, Port, McCullough, Pisoni), Ann Arbor, Mich.; ERA-EDTA Registry (Jager), Department of Medical Informatics, Academic Medical Centre, Amsterdam Public Health Research Institute, University of Amsterdam, Amsterdam, Netherlands; Wolfson Palliative Care Research Centre (Murtagh), Hull York Medical School, University of Hull, Hull, UK; VA Puget Sound Health Care System (O'Hare), Seattle, Wash.; Department of Blood Purification (Hanafusa), Tokyo Women's Medical University, Tokyo, Japan; Departments of Epidemiology (Morgenstern) and Environmental Health Sciences (Morgenstern), School of Public Health, and Department of Urology (Morgenstern), Medical School, University of Michigan, Ann Arbor, Mich.; DaVita Outcomes Research and Patient Empowerment (Tentori), Denver, Colo.; Divisions of Nephrology (Perlman, Swartz) and Palliative Care (Swartz), Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Mich
| | - Richard D Swartz
- University Health Network (Jassal), Toronto, Ont.; Arbor Research Collaborative for Health (Larkina, Port, McCullough, Pisoni), Ann Arbor, Mich.; ERA-EDTA Registry (Jager), Department of Medical Informatics, Academic Medical Centre, Amsterdam Public Health Research Institute, University of Amsterdam, Amsterdam, Netherlands; Wolfson Palliative Care Research Centre (Murtagh), Hull York Medical School, University of Hull, Hull, UK; VA Puget Sound Health Care System (O'Hare), Seattle, Wash.; Department of Blood Purification (Hanafusa), Tokyo Women's Medical University, Tokyo, Japan; Departments of Epidemiology (Morgenstern) and Environmental Health Sciences (Morgenstern), School of Public Health, and Department of Urology (Morgenstern), Medical School, University of Michigan, Ann Arbor, Mich.; DaVita Outcomes Research and Patient Empowerment (Tentori), Denver, Colo.; Divisions of Nephrology (Perlman, Swartz) and Palliative Care (Swartz), Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Mich
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