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Rajasekaran A, Prakash A, Hatch S, Lu Y, Cutter GR, Zarjou A. Advocating for in-center hemodialysis patients via anonymous survey. Medicine (Baltimore) 2022; 101:e30937. [PMID: 36254033 PMCID: PMC9575770 DOI: 10.1097/md.0000000000030937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
We conducted an anonymous survey in 9 of our university affiliated outpatient dialysis units to address the concern that many in-center hemodialysis patients may not feel comfortable sharing their experiences. Major goals of this study: Investigating level of patient satisfaction with their care; Evaluating the subjective perception of the level of understanding of patients regarding pertinent issues of their disease and its management; Identifying potential avenues for care improvement. Survey was conducted in English, paper-based, with answer choices to individual questions for patient satisfaction and education graded using a 5-point Likert scale. Regarding potential areas of improvement, patients were asked to choose as many areas as deemed appropriate. To ensure anonymity, the completed surveys were folded and dropped into a box. Overall, 253 out of 516 (49%) screened patients were eligible and completed the survey. Patients expressed favorable responses regarding satisfaction (mean rating > 4 in each of 14 questions) and education (mean rating > 4 in 8 questions, > 3.5 in 2 questions) regarding hemodialysis. About 62% of overall study participants identified at least one area where they felt additional information would result in improvement of care. Our results indicate that patients undergoing outpatient hemodialysis were overall satisfied and had a good perceptive understanding about their health. Based on the patients' input, strategies focused on addressing pain and discomfort, privacy, providing information about palliative care/hospice, mental health resources, and the process of kidney transplantation may promote improvement in overall quality of care.
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Affiliation(s)
- Arun Rajasekaran
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, AL, USA
| | - Anand Prakash
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, AL, USA
| | - Spencer Hatch
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, AL, USA
| | - Yan Lu
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, AL, USA
| | - Gary R. Cutter
- Division of Biostatistics, University of Alabama at Birmingham, AL, USA
| | - Abolfazl Zarjou
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, AL, USA
- *Correspondence: Abolfazl Zarjou, Assistant Professor of Medicine, Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, 618 Zeigler Research Building, 703 South 19th Street Birmingham, AL 35294, USA (e-mail: )
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Tavares APDS, Santos CGDS, Tzanno-Martins C, Barros Neto J, Silva AMMD, Lotaif L, Souza JVL. Kidney supportive care: an update of the current state of the art of palliative care in CKD patients. ACTA ACUST UNITED AC 2020; 43:74-87. [PMID: 32897286 PMCID: PMC8061961 DOI: 10.1590/2175-8239-jbn-2020-0017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 07/06/2020] [Indexed: 11/24/2022]
Abstract
Chronic kidney disease (CKD) has become a public health burden worldwide for its increasing incidence and prevalence, high impact on the health related quality of life (HRQoL) and life expectancy, and high personal and social cost. Patients with advanced CKD, in dialysis or not, suffer a burden from symptoms very similar to other chronic diseases and have a life span not superior to many malignancies. Accordingly, in recent years, renal palliative care has been recommended to be integrated in the traditional care delivered to this population. This research provides an updated overview on renal palliative care from the relevant literature.
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Affiliation(s)
- Alze Pereira Dos Santos Tavares
- Sociedade Brasileira de Nefrologia, Comitê de Cuidados Paliativos, São Paulo, SP, Brasil.,Hospital Santa Paula, São Paulo, SP, Brasil
| | - Cássia Gomes da Silveira Santos
- Sociedade Brasileira de Nefrologia, Comitê de Cuidados Paliativos, São Paulo, SP, Brasil.,Universidade Federal do Paraná, Hospital das Clínicas, Curitiba, PR, Brasil
| | - Carmen Tzanno-Martins
- Sociedade Brasileira de Nefrologia, Comitê de Cuidados Paliativos, São Paulo, SP, Brasil.,Clínica de Hemodiálise, São Paulo, SP, Brasil
| | - José Barros Neto
- Sociedade Brasileira de Nefrologia, Comitê de Cuidados Paliativos, São Paulo, SP, Brasil.,Sociedade Brasileira de Nefrologia Mineira, Belo Horizonte, MG, Brasil.,Felício Rocho Hospital, Departamento de Nefrologia, Belo Horizonte, MG, Brasil
| | | | - Leda Lotaif
- Sociedade Brasileira de Nefrologia, Comitê de Cuidados Paliativos, São Paulo, SP, Brasil.,Instituto Dante Pazzanese de Cardiologia, Nefrologia e Hipertensão e Pós-Graduação, São Paulo, SP, Brasil.,HCor, São Paulo, SP, Brasil
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Roderick P, Rayner H, Tonkin-Crine S, Okamoto I, Eyles C, Leydon G, Santer M, Klein J, Yao GL, Murtagh F, Farrington K, Caskey F, Tomson C, Loud F, Murphy E, Elias R, Greenwood R, O’Donoghue D. A national study of practice patterns in UK renal units in the use of dialysis and conservative kidney management to treat people aged 75 years and over with chronic kidney failure. Health Services and Delivery Research 2015. [DOI: 10.3310/hsdr03120] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundConservative kidney management (CKM) is recognised as an alternative to dialysis for a significant number of older adults with multimorbid stage 5 chronic kidney disease (CKD5). However, little is known about the way CKM is delivered or how it is perceived.AimTo determine the practice patterns for the CKM of older patients with CKD5, to inform service development and future research.Objectives(1) To describe the differences between renal units in the extent and nature of CKM, (2) to explore how decisions are made about treatment options for older patients with CKD5, (3) to explore clinicians’ willingness to randomise patients with CKD5 to CKM versus dialysis, (4) to describe the interface between renal units and primary care in managing CKD5 and (5) to identify the resources involved and potential costs of CKM.MethodsMixed-methods study. Interviews with 42 patients aged > 75 years with CKD5 and 60 renal unit staff in a purposive sample of nine UK renal units. Interviews informed the design of a survey to assess CKM practice, sent to all 71 UK units. Nineteen general practitioners (GPs) were interviewed concerning the referral of CKD patients to secondary care. We sought laboratory data on new CKD5 patients aged > 75 years to link with the nine renal units’ records to assess referral patterns.ResultsSixty-seven of 71 renal units completed the survey. Although terminology varied, there was general acceptance of the role of CKM. Only 52% of units were able to quantify the number of CKM patients. A wide range reflected varied interpretation of the designation ‘CKM’ by both staff and patients. It is used to characterise a future treatment option as well as non-dialysis care for end-stage kidney failure (i.e. a disease state equivalent to being on dialysis). The number of patients in the latter group on CKM was relatively small (median 8, interquartile range 4.5–22). Patients’ expectations of CKM and dialysis were strongly influenced by renal staff. In a minority of units, CKM was not discussed. When discussed, often only limited information about illness progression was provided. Staff wanted more research into the relative benefits of CKM versus dialysis. There was almost universal support for an observational methodology and a quarter would definitely be willing to participate in a randomised clinical trial, indicating that clinicians placed value on high-quality evidence to inform decision-making. Linked data indicated that most CKD5 patients were known to renal units. GPs expressed a need for guidance on when to refer older multimorbid patients with CKD5 to nephrology care. There was large variation in the scale and model of CKM delivery. In most, the CKM service was integrated within the service for all non-renal replacement therapy CKD5 patients. A few units provided dedicated CKM clinics and some had dedicated, modest funding for CKM.ConclusionsConservative kidney management is accepted across UK renal units but there is much variation in the way it is described and delivered. For best practice, and for CKM to be developed and systematised across all renal units in the UK, we recommend (1) a standard definition and terminology for CKM, (2) research to measure the relative benefits of CKM and dialysis and (3) development of evidence-based staff training and patient education interventions.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Paul Roderick
- Primary Care and Population Sciences, University of Southampton, UK
| | - Hugh Rayner
- Department of Renal Medicine, Heart of England NHS Foundation Trust, Birmingham, UK
| | | | - Ikumi Okamoto
- Primary Care and Population Sciences, University of Southampton, UK
| | - Caroline Eyles
- Primary Care and Population Sciences, University of Southampton, UK
| | - Geraldine Leydon
- Primary Care and Population Sciences, University of Southampton, UK
| | - Miriam Santer
- Primary Care and Population Sciences, University of Southampton, UK
| | - Jonathan Klein
- Southampton Management School, University of Southampton, UK
| | - Guiqing Lily Yao
- Primary Care and Population Sciences, University of Southampton, UK
| | - Fliss Murtagh
- Cicely Saunders Institute, King’s College London, UK
| | | | | | | | | | - Emma Murphy
- Cicely Saunders Institute, King’s College London, UK
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Tonkin-Crine S, Okamoto I, Leydon GM, Murtagh FEM, Farrington K, Caskey F, Rayner H, Roderick P. Understanding by older patients of dialysis and conservative management for chronic kidney failure. Am J Kidney Dis 2014; 65:443-50. [PMID: 25304984 PMCID: PMC4339698 DOI: 10.1053/j.ajkd.2014.08.011] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Accepted: 08/01/2014] [Indexed: 11/11/2022]
Abstract
Background Older adults with chronic kidney disease stage 5 may be offered a choice between dialysis and conservative management. Few studies have explored patients’ reasons for choosing conservative management and none have compared the views of those who have chosen different treatments across renal units. Study Design Qualitative study with semistructured interviews. Settings & Participants Patients 75 years or older recruited from 9 renal units. Units were chosen to reflect variation in the scale of delivery of conservative management. Methodology Semistructured interviews audiorecorded and transcribed verbatim. Analytical Approach Data were analyzed using thematic analysis. Results 42 interviews were completed, 4 to 6 per renal unit. Patients were sampled from those receiving dialysis, those preparing for dialysis, and those choosing conservative management. 14 patients in each group were interviewed. Patients who had chosen different treatments held varying beliefs about what dialysis could offer. The information that patients reported receiving from clinical staff differed between units. Patients from units with a more established conservative management pathway were more aware of conservative management, less often believed that dialysis would guarantee longevity, and more often had discussed the future with staff. Some patients receiving conservative management reported that they would have dialysis if they became unwell in the future, indicating the conditional nature of their decision. Limitations Recruitment of older adults with frailty and comorbid conditions was difficult and therefore transferability of findings to this population is limited. Conclusions Older adults with chronic kidney disease stage 5 who have chosen different treatment options have contrasting beliefs about the likely outcomes of dialysis for those who are influenced by information provided by renal units. Supporting renal staff in discussing conservative management as a valid alternative to dialysis for a subset of patients will aid informed decision making. There is a need for better evidence about conservative management to support shared decision making for older people with chronic kidney failure.
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Affiliation(s)
- Sarah Tonkin-Crine
- Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, United Kingdom.
| | - Ikumi Okamoto
- Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Geraldine M Leydon
- Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Fliss E M Murtagh
- Department of Palliative Care, Policy and Rehabilitation, King's College London, London, United Kingdom
| | | | - Fergus Caskey
- Renal Unit, Southmead Hospital, Bristol, United Kingdom
| | - Hugh Rayner
- Department of Renal Medicine, Heart of England NHS Foundation Trust, Birmingham, United Kingdom
| | - Paul Roderick
- Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
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Ishikawa H, Ogihara N, Tsukushi S, Sakamoto J. Withdrawal from Dialysis and Palliative Care for Severely Ill Dialysis Patients in terms of Patient-Centered Medicine. Case Rep Nephrol 2013; 2013:761691. [PMID: 24558626 DOI: 10.1155/2013/761691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2013] [Accepted: 11/05/2013] [Indexed: 11/18/2022] Open
Abstract
We treated a dementia patient with end stage chronic kidney disease (CKD). The patient also had severe chronic heart disease and suffered from untreatable respiratory distress during the clinical course of his illness. We therefore initiated peritoneal dialysis therapy (PD) as renal replacement therapy, although we had difficulties continuing stable PD for many reasons, including a burden on caregivers and complications associated with PD therapy itself. Under these circumstances we considered that palliative care prior to intensive care may have been an optional treatment. This was a distressing decision regarding end-of-life care for this patient. We were unable to confirm the patient's preference for end-of-life care due to his dementia. Following sufficiently informed consent the patient's family accepted withdrawal from dialysis (WD). We simultaneously initiated nonabandonment and continuation of careful follow-up including palliative care. We concluded that the end-of-life care we provided would contribute to a peaceful and dignified death of the patient. Although intensive care based on assessment of disease is important, there is a limitation to care, and therefore we consider that WD and palliative care are acceptable options for care of our patients in the terminal phase of their lives.
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Abstract
PURPOSE OF REVIEW At present, clinicians and healthcare providers are increasingly urged to advance the provision of state-of-the-art palliative care for patients with incurable cancer. This review provides an overview about the recent findings and practical suggestions. RECENT FINDINGS In the last decade, the awareness about the logistic and personal resources needed to meet the somatic and psychological needs of patients with progressive and life-threatening diseases has increased and in parallel, palliative care concepts and expertise have evolved substantially. Care concepts for patients with metastatic cancer emphasized the potential of interdisciplinary care. For example, in 2010, a randomized trial reported a benefit for patients with lung cancer who received early palliative care in addition to routine care. It is discussed that this was because of increased quality of life and detailed exploration of patient preferences. SUMMARY Patients, families and physicians benefit from shared care concepts of oncology and specialized palliative care. Although this concept is already becoming increasingly implemented in tertiary (comprehensive cancer-) care settings, the potential of this approach should be explored for other clinical settings such as office-based oncology.
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Schell JO, Patel UD, Steinhauser KE, Ammarell N, Tulsky JA. Discussions of the kidney disease trajectory by elderly patients and nephrologists: a qualitative study. Am J Kidney Dis 2012; 59:495-503. [PMID: 22221483 DOI: 10.1053/j.ajkd.2011.11.023] [Citation(s) in RCA: 182] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2011] [Accepted: 11/16/2011] [Indexed: 11/11/2022]
Abstract
BACKGROUND Elderly patients with advanced kidney disease experience considerable disability, morbidity, and mortality. Little is known about the impact of physician-patient interactions on patient preparation for the illness trajectory. We sought to describe how nephrologists and older patients discuss and understand the prognosis and course of kidney disease leading to renal replacement therapy. METHODS We conducted focus groups and interviews with 11 nephrologists and 29 patients older than 65 years with advanced chronic kidney disease or receiving hemodialysis. Interviews were audiorecorded and transcribed. We used qualitative analytic methods to identify common and recurrent themes related to the primary research question. RESULTS We identified 6 themes that describe how the kidney disease trajectory is discussed and understood: (1) patients are shocked by their diagnosis, (2) patients are uncertain how their disease will progress, (3) patients lack preparation for living with dialysis, (4) nephrologists struggle to explain illness complexity, (5) nephrologists manage a disease over which they have little control, and (6) nephrologists tend to avoid discussions of the future. Patients and nephrologists acknowledged that prognosis discussions are rare. Patients tended to cope with thoughts of the future through avoidance by focusing on their present clinical status. Nephrologists reported uncertainty and concern for evoking negative reactions as barriers to these conversations. CONCLUSIONS Patients and nephrologists face challenges in understanding and preparing for the kidney disease trajectory. Communication interventions that acknowledge the role of patient emotion and address uncertainty may improve how nephrologists discuss disease trajectory with patients and thereby enhance their understanding and preparation for the future.
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Affiliation(s)
- Jane O Schell
- Department of Medicine, Duke University, Durham, NC; Center for Health Services Research in Primary Care, Durham VA Medical Center, Durham, NC 27705, USA.
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Okon TR, Vats HS, Dart RA. Palliative medicine referral in patients undergoing continuous renal replacement therapy for acute kidney injury. Ren Fail 2011; 33:707-17. [PMID: 21787162 DOI: 10.3109/0886022x.2011.589946] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Referral patterns for palliative medicine consultation (PMC) by intensivists for patients requiring continuous renal replacement therapy (CRRT) have not been studied. METHODS We retrospectively analyzed clinical data on patients who received CRRT in a tertiary referral center between 1999 and 2006 to determine timeliness and effectiveness of PMC referrals and mortality rate as a surrogate for safety among patients receiving CRRT for acute kidney injury. RESULTS Over one-fifth (21.1%) of the 230 CRRT patients studied were referred for PMC (n = 55). PMC was requested on average after median of 15 hospital and 13 intensive care unit (ICU) days. Multivariate regression analysis revealed no association between mortality risk and PMC. Total hospital length of stay for patients who died after PMC referral was 18.5 (95% CI = 15-25) days compared with 12.5 days (95% CI = 9-17) for patients who died without PMC referral. ICU care for patients who died and received PMC was longer than for patients with no PMC [11.5 (95% CI = 9-15) days vs. 7.0 (95% CI = 6-9) days, p < 0.01]. CRRT duration was longer for patients who died and received PMC referral than for those without PMC [5.5 (95% CI = 4-8) vs. 3.0 (95% CI = 3-4) days; p < 0.01]. CONCLUSIONS PMC was safe, but referrals were delayed and ineffective in optimizing the utilization of intensive care in patients receiving CRRT. A proactive, "triggered" referral process will likely be necessary to improve timeliness of PMC and reduce duration of non-beneficial life-sustaining therapies.
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Affiliation(s)
- Tomasz R Okon
- Department of Palliative Medicine, Marshfield Clinic, Marshfield, WI 54449, USA.
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Latos DL, Lucas J. Geriatric nephrology: a paradigm shift in the approach to renal replacement therapy. Adv Chronic Kidney Dis 2011; 18:412-9. [PMID: 22098659 DOI: 10.1053/j.ackd.2011.09.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2011] [Revised: 09/23/2011] [Accepted: 09/26/2011] [Indexed: 11/11/2022]
Abstract
The population of elderly individuals diagnosed with CKD continues to grow. Many have multiple comorbid conditions that will impact life expectancy as well as decisions about whether to pursue renal replacement therapy. Nephrologists are uniquely positioned to assist their patients and caregivers in this regard and spend considerable time counseling them about the benefits and risks associated with dialysis therapy. This article presents an overview of many of the issues facing nephrologists, and provides tools to assist busy clinicians in helping their elderly patients in deciding whether to consider dialysis or intensive, nondialysis care.
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