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Ernecoff NC, Robinson MT, Motter EM, Bursic AE, Lagnese K, Taylor R, Lupu D, Schell JO. Concurrent Hospice and Dialysis Care: Considerations for Implementation. J Gen Intern Med 2024; 39:798-807. [PMID: 37962726 PMCID: PMC11043284 DOI: 10.1007/s11606-023-08504-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 10/20/2023] [Indexed: 11/15/2023]
Abstract
IMPORTANCE Hospice positively impacts care at the end of life for patients and their families. However, compared to the general Medicare population, patients on dialysis are half as likely to receive hospice. Concurrent hospice and dialysis care offers an opportunity to improve care for people living with end-stage kidney disease (ESKD). OBJECTIVE We sought to (1) develop a conceptual model of the Program and (2) identify key components, resources, and considerations for further implementation. DESIGN We conducted a template analysis of qualitative interviews and convened a community advisory panel (CAP) to get feedback on current concurrent care design and considerations for dissemination and implementation. PARTICIPANTS Thirty-nine patients with late-stage chronic kidney disease (CKD), family caregivers, bereaved family caregivers, hospice clinicians, nephrology clinicians, administrators, and policy experts participated in interviews. A purposive subset of 19 interviewees composed the CAP. MAIN MEASURES Qualitative feedback on concurrent care design refinements, implementation, and resources. KEY RESULTS Participants identified four themes that define an effective model of concurrent hospice and dialysis: it requires (1) timely goals-of-care conversations and (2) an interdisciplinary approach; (3) clear guidelines ensure smooth transitions for patients and families; and (4) hospice payment policy must support concurrent care. CAP participants provided feedback on the phases of an effective model of concurrent hospice and dialysis, and resources, including written and interactive educational materials, communication tools, workflow processes, and order sets. CONCLUSIONS We developed a conceptual model for concurrent hospice and dialysis care and a corresponding resource list. In addition to policy changes, clinical implementation and educational resources can facilitate scalable and equitable dissemination of concurrent care. Concurrent hospice and dialysis care must be systematically evaluated via a hybrid implementation-effectiveness trial that includes the resources outlined herein, based on our conceptual model of concurrent care delivery.
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Affiliation(s)
| | - Mayumi T Robinson
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Erica M Motter
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Alexandra E Bursic
- Division of Renal-Electrolyte, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Keith Lagnese
- Optum Home & Community Care, Landmark Health, Huntington Beach, CA, USA
| | | | - Dale Lupu
- School of Nursing, George Washington University, Washington, DC, USA
| | - Jane O Schell
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Division of Renal-Electrolyte, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Dialysis Clinic, Inc, Nashville, TN, USA
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Mandel EI, Fox M, Schell JO, Cohen RA. Shared Decision-Making and Patient Communication in Nephrology Practice. Adv Kidney Dis Health 2024; 31:5-12. [PMID: 38403394 DOI: 10.1053/j.akdh.2023.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 11/22/2023] [Accepted: 12/06/2023] [Indexed: 02/27/2024]
Abstract
Shared decision-making (SDM) is the standard of care for patient or surrogates and their clinicians to arrive at a medical decision. Evidence suggests that SDM increases patients' understanding of their illness and satisfaction with their decision-making process. Dialysis patients often report the perception that they were passive participants in the decision to start dialysis, suggesting further opportunities for enhancing the application of SDM in decision-making with patients with kidney disease. The hallmark feature of SDM is sensitive, culturally- and equity-informed communication and effective partnership between patient or surrogate and clinician. In the process, the patient's personal expertise in the realm of their values and priorities is elicited, and the clinician's medical expertise is shared. The integration of this shared expertise then leads to an informed treatment decision. Frameworks such as the Serious Illness Conversation Guide and REMAP are guides for the SDM process, and communication tools and mnemonics can help facilitate SDM conversations. This paper will address SDM in nephrology practice, reviewing underlying supportive evidence, context, and timing for employing SDM in the trajectory of chronic kidney disease and acute kidney injury, special considerations in vulnerable populations to promote health equity, and communication tools and frameworks to facilitate the SDM process. By learning and applying these frameworks and tools, nephrology providers will be able to employ SDM in the management of kidney disease.
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Affiliation(s)
- Ernest I Mandel
- Division of Renal Medicine, Brigham and Women's Hospital, Department of Medicine, Hebrew SeniorLife, Harvard Medical School, Boston, MA.
| | - Monica Fox
- National Kidney Foundation of Illinois, Chicago, IL
| | - Jane O Schell
- Section of Palliative Care and Medical Ethics, Division of General Medicine and Division of Renal-Electrolyte, UPMC Health System, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Robert A Cohen
- Nephrology Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
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Davison SN, Pommer W, Brown MA, Douglas CA, Gelfand SL, Gueco IP, Hole BD, Homma S, Kazancıoğlu RT, Kitamura H, Koubar SH, Krause R, Li KC, Lowney AC, Nagaraju SP, Niang A, Obrador GT, Ohtake Y, Schell JO, Scherer JS, Smyth B, Tamba K, Vallath N, Wearne N, Zakharova E, Zúñiga C, Brennan FP. Conservative kidney management and kidney supportive care: core components of integrated care for people with kidney failure. Kidney Int 2024; 105:35-45. [PMID: 38182300 DOI: 10.1016/j.kint.2023.10.001] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 09/20/2023] [Accepted: 10/02/2023] [Indexed: 01/07/2024]
Abstract
Integrated kidney care requires synergistic linkage between preventative care for people at risk for chronic kidney disease and health services providing care for people with kidney disease, ensuring holistic and coordinated care as people transition between acute and chronic kidney disease and the 3 modalities of kidney failure management: conservative kidney management, transplantation, and dialysis. People with kidney failure have many supportive care needs throughout their illness, regardless of treatment modality. Kidney supportive care is therefore a vital part of this integrated framework, but is nonexistent, poorly developed, and/or poorly integrated with kidney care in many settings, especially in low- and middle-income countries. To address this, the International Society of Nephrology has (i) coordinated the development of consensus definitions of conservative kidney management and kidney supportive care to promote international understanding and awareness of these active treatments; and (ii) identified key considerations for the development and expansion of conservative kidney management and kidney supportive care programs, especially in low resource settings, where access to kidney replacement therapy is restricted or not available. This article presents the definitions for conservative kidney management and kidney supportive care; describes their core components with some illustrative examples to highlight key points; and describes some of the additional considerations for delivering conservative kidney management and kidney supportive care in low resource settings.
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Affiliation(s)
- Sara N Davison
- Division of Nephrology and Immunology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.
| | - Wolfgang Pommer
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, Berlin, Germany; Kuratorium für Dialyse und Nierentransplantation, Neu-Isenburg, Germany
| | - Mark A Brown
- Department of Renal Medicine, St George Hospital, Kogarah, Australia; School of Clinical Medicine, University of New South Wales, Kogarah, Australia
| | - Claire A Douglas
- Department of Renal Medicine, Ninewells Hospital, Dundee, Scotland, UK
| | - Samantha L Gelfand
- Division of Renal (Kidney) Medicine, Department of Psychosocial Oncology and Palliative Care, Brigham and Women's Hospital, Boston, Massachusetts, USA; Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA
| | - Irmingarda P Gueco
- Section of Nephrology, The Medical City, Pasig City, National Capital Region, Philippines
| | - Barnaby D Hole
- Department of Population Health, University of Bristol, Bristol, UK
| | - Sumiko Homma
- Department of Nephrology, Koga Red Cross Hospital, Koga, Ibaraki, Japan
| | - Rümeyza T Kazancıoğlu
- Division of Nephrology, Faculty of Medicine, Bezmialem Vakif University, Istanbul, Türkiye
| | - Harumi Kitamura
- Department of Clinical Quality Management, Osaka University Hospital, Osaka, Japan
| | - Sahar H Koubar
- Division of Nephrology and Hypertension, Department of Internal Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Rene Krause
- Division of Interdisciplinary Palliative Care and Medicine, Department of Family Community and Emergency Care, University of Cape Town, Cape Town, South Africa
| | - Kelly C Li
- Department of Renal Medicine, St George Hospital, Kogarah, Australia; School of Clinical Medicine, University of New South Wales, Kogarah, Australia
| | - Aoife C Lowney
- Department of Palliative Medicine, Marymount University Hospital and Hospice, Cork, Ireland; Department of Palliative Medicine, Cork University Hospital, Cork, Ireland; Department of Palliative Medicine, University College Cork, Cork, Ireland
| | - Shankar P Nagaraju
- Department of Nephrology, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, India
| | - Abdou Niang
- Nephrology Department, Cheikh Anta Diop University, Dakar, Senegal
| | - Gregorio T Obrador
- Department of Biostatistics and Public Health, Universidad Panamericana School of Medicine, Mexico City, Mexico
| | | | - Jane O Schell
- Section of Palliative Care and Medical Ethics, Renal-Electrolyte Division, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jennifer S Scherer
- Department of Internal Medicine, NYU Grossman School of Medicine, New York, New York, USA
| | - Brendan Smyth
- Department of Renal Medicine, St George Hospital, Kogarah, Australia; School of Clinical Medicine, University of New South Wales, Kogarah, Australia; National Health and Medical Research Council (NHMRC) Clinical Trials Centre, University of Sydney, Camperdown, Australia
| | - Kaichiro Tamba
- Division of Palliative Care Medicine, Juchi Medical School University Hospital, Tochigi, Japan
| | - Nandini Vallath
- Department of Palliative Medicine, St Johns National Academy of Health Sciences, Bengaluru, India
| | - Nicola Wearne
- Division of Nephrology and Hypertension, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | | | - Carlos Zúñiga
- Facultad de Medicina, Universidad Católica de la Santísima Concepción, Concepción, Chile
| | - Frank P Brennan
- Kuratorium für Dialyse und Nierentransplantation, Neu-Isenburg, Germany; Department of Renal Medicine, St George Hospital, Kogarah, Australia
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Schell JO, Schenker Y, Piscitello G, Belin SC, Chiu EJ, Zapf RL, Kip PL, Marroquin OC, Donahoe MP, Holder-Murray J, Arnold RM. Implementing a Serious Illness Risk Prediction Model: Impact on Goals of Care Documentation. J Pain Symptom Manage 2023; 66:603-610.e3. [PMID: 37532159 PMCID: PMC10828667 DOI: 10.1016/j.jpainsymman.2023.07.015] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 07/17/2023] [Accepted: 07/22/2023] [Indexed: 08/04/2023]
Abstract
CONTEXT Goals of care conversations can promote high value care for patients with serious illness, yet documented discussions infrequently occur in hospital settings. OBJECTIVES We sought to develop a quality improvement initiative to improve goals of care documentation for hospitalized patients. METHODS Implementation occurred at an academic medical center in Pittsburgh, Pennsylvania. Intervention included integration of a 90-day mortality prediction model grouping patients into low, intermediate, and high risk; a centralized goals of care note; and automated notifications and targeted palliative consults. We compared documented goals of care discussions by risk score before and after implementation. RESULTS Of the 12,571 patients hospitalized preimplementation and 10,761 postimplementation, 1% were designated high risk and 11% intermediate risk of mortality. Postimplementation, goals of care documentation increased for high (17.6%-70.8%, P< 0.0001) and intermediate risk patients (9.6%-28.0%, P < 0.0001). For intermediate risk patients, the percentage of goals of care documentation performed by palliative medicine specialists increased from pre- to postimplementation (52.3%-71.2%, P = 0.0002). For high-risk patients, the percentage of goals of care documentation completed by the primary service increased from pre-to postimplementation (36.8%-47.1%, P = 0.5898, with documentation performed by palliative medicine specialists slightly decreasing from pre- to postimplementation (63.2%-52.9%, P = 0.5898). CONCLUSIONS Implementation of a goals of care initiative using a mortality prediction model significantly increased goals of care documentation especially among high-risk patients. Further study to assess strategies to increase goals of care documentation for intermediate risk patients is needed especially by nonspecialty palliative care.
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Affiliation(s)
- Jane O Schell
- Section of Palliative Care and Medical Ethics (J.O.S., Y.S., G.P., R.M.A.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Renal-Electrolyte Division (J.O.S.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Palliative Research Center (J.O.S., Y.S., G.P., S.C.B., E.J.C., R.M.A.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
| | - Yael Schenker
- Section of Palliative Care and Medical Ethics (J.O.S., Y.S., G.P., R.M.A.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Palliative Research Center (J.O.S., Y.S., G.P., S.C.B., E.J.C., R.M.A.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Gina Piscitello
- Section of Palliative Care and Medical Ethics (J.O.S., Y.S., G.P., R.M.A.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Palliative Research Center (J.O.S., Y.S., G.P., S.C.B., E.J.C., R.M.A.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Shane C Belin
- Palliative Research Center (J.O.S., Y.S., G.P., S.C.B., E.J.C., R.M.A.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Eric J Chiu
- Palliative Research Center (J.O.S., Y.S., G.P., S.C.B., E.J.C., R.M.A.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Rachel L Zapf
- Wolff Center (R.L.Z., P.L.K., R.M.A.), UPMC, Pittsburgh, Pennsylvania
| | - Paula L Kip
- Wolff Center (R.L.Z., P.L.K., R.M.A.), UPMC, Pittsburgh, Pennsylvania
| | | | - Michael P Donahoe
- Division of Pulmonary, Allergy, and Critical Care Medicine (M.P.D.), Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Jennifer Holder-Murray
- Departments of Surgery and Anesthesiology and Perioperative Medicine (J.H.M.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Robert M Arnold
- Section of Palliative Care and Medical Ethics (J.O.S., Y.S., G.P., R.M.A.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Palliative Research Center (J.O.S., Y.S., G.P., S.C.B., E.J.C., R.M.A.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Wolff Center (R.L.Z., P.L.K., R.M.A.), UPMC, Pittsburgh, Pennsylvania
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Ernecoff NC, Motter EM, Robinson MT, Lagnese K, Taylor R, Schell JO. Perspectives of Caregivers and Clinicians on a Concurrent Hospice and Dialysis Program: A Qualitative Analysis. Am J Kidney Dis 2023; 82:373-376. [PMID: 36965826 DOI: 10.1053/j.ajkd.2023.01.450] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Accepted: 01/17/2023] [Indexed: 03/27/2023]
Affiliation(s)
| | - Erica M Motter
- Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Mayumi T Robinson
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | | | | | - Jane O Schell
- Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Renal-Electrolyte Division, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Saeed F, Schell JO. Shared Decision Making for Older Adults: Time to Move Beyond Dialysis as a Default. Ann Intern Med 2023; 176:129-130. [PMID: 36534979 PMCID: PMC10101214 DOI: 10.7326/m22-3431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Affiliation(s)
- Fahad Saeed
- Divisions of Nephrology and Palliative Care, Departments of Medicine and Public Health, University of Rochester Medical Center, Rochester, New York
| | - Jane O Schell
- Renal-Electrolyte Division, and Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Ernecoff NC, Bursic AE, Motter EM, Lagnese K, Taylor R, Schell JO. Description and Outcomes of an Innovative Concurrent Hospice-Dialysis Program. J Am Soc Nephrol 2022; 33:1942-1950. [PMID: 35820784 PMCID: PMC9528329 DOI: 10.1681/asn.2022010064] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 06/21/2022] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Compared with the general Medicare population, patients with ESKD have worse quality metrics for end-of-life care, including a higher percentage experiencing hospitalizations and in-hospital deaths and a lower percentage referred to hospice. We developed a Concurrent Hospice and Dialysis Program in which patients may receive palliative dialysis alongside hospice services. The Program aims to improve access to quality end-of-life care and, ultimately, improve the experiences of patients, caregivers, and clinicians. OBJECTIVES We sought to describe (1) the Program and (2) enrollment and utilization characteristics of Program participants. METHODS We conducted a quantitative description of demographics, patient characteristics, and utilization of Program enrollees. RESULTS Of 43 total enrollees, 44% received at least one dialysis treatment, whereas 56% received no dialysis. The median (range) hospice length of stay was 9 (1-76) days for all participants and 13 (4-76) days for those who received at least one dialysis treatment. The average number of dialysis treatments was 3.5 (range 1-9) for hemodialysis and 19.2 (range 3-65) for peritoneal dialysis. Sixty-five percent of enrollees died at home, 23% in inpatient hospice, and 12% in a nursing facility; no patients died in the hospital. CONCLUSIONS Our 3-year experience with the Program demonstrated that enrollees had a longer median hospice stay than the previously reported 5-day median for patients with ESKD. Most patients received no further dialysis treatments despite the option to continue dialysis. Our experience provides evidence to support future work testing the effectiveness of such clinical programs to improve patient and utilization outcomes.
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Affiliation(s)
| | - Alexandra E. Bursic
- Renal-Electrolyte Division, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Erica M. Motter
- Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | | | | | - Jane O. Schell
- Renal-Electrolyte Division, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Ernecoff NC, Bell LF, Arnold RM, Shea CM, Switzer GE, Jhamb M, Schell JO, Kavalieratos D. Clinicians' Perceptions of Collaborative Palliative Care Delivery in Chronic Kidney Disease. J Pain Symptom Manage 2022; 64:168-177. [PMID: 35417752 PMCID: PMC9276626 DOI: 10.1016/j.jpainsymman.2022.04.167] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 03/29/2022] [Accepted: 04/05/2022] [Indexed: 11/20/2022]
Abstract
CONTEXT Guidelines recommend palliative care for patients with chronic kidney disease (CKD), who experience a high pain and symptom burden, and receive intensive treatments that often do not align with their values. A lack of scalable specialty palliative care services has prompted calls for attention to primary palliative care, delivered in primary care and nephrology settings. OBJECTIVES The objectives of this study were to 1) describe expectations for care to meet the palliative care needs of people living with CKD, and limitations to meeting those expectations in the current model, and 2) identify potential interventions to meet patients' palliative care needs. METHODS We conducted semi-structured interviews with clinicians from primary care, nephrology, and palliative care to assess 1) reasonable expectations for meeting palliative needs, 2) barriers to integrating primary palliative care, and 3) potential intervention points. RESULTS Clinicians discussed their expectations for high-quality communication (e.g., discussing disease understanding, assessing goals of care) and better integration of palliative care services. Clinicians expressed barriers to delivering that care, including poor inter-clinician communication. To address barriers, clinicians outlined potential intervention points, such as building collaborative models of care, and structural triggers to identify patients who may be appropriate for palliative care. CONCLUSION Interventions to address gaps in palliative care delivery for people living with CKD should incorporate systematic identification of patients with palliative care needs and structural mechanisms to meeting those needs via specialty and primary palliative care.
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Affiliation(s)
- Natalie C Ernecoff
- RAND Corporation (N.C.E.), Pittsburgh, Pennsylvania, USA; Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh (N.C.E., L.F.B., R.M.A., J.O.S.), Pittsburgh, Pennsylvania, USA.
| | - Lindsay F Bell
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh (N.C.E., L.F.B., R.M.A., J.O.S.), Pittsburgh, Pennsylvania, USA
| | - Robert M Arnold
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh (N.C.E., L.F.B., R.M.A., J.O.S.), Pittsburgh, Pennsylvania, USA
| | - Christopher M Shea
- Department of Health Policy and Management, University of North Carolina at Chapel Hill (C.M.S.), Chapel Hill, North Carolina, USA
| | - Galen E Switzer
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh (G.E.S.), Pittsburgh, Pennsylvania, USA; Department of Psychiatry, University of Pittsburgh (G.E.S.), Pittsburgh, Pennsylvania, USA; Department of Clinical and Translational Science, University of Pittsburgh (G.E.S.), Pittsburgh, Pennsylvania, USA; Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System (G.E.S.), Pittsburgh, Pennsylvania, USA
| | - Manisha Jhamb
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh (M.J.), Pittsburgh, Pennsylvania, USA
| | - Jane O Schell
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh (N.C.E., L.F.B., R.M.A., J.O.S.), Pittsburgh, Pennsylvania, USA
| | - Dio Kavalieratos
- Division of Palliative Medicine, Department of Family and Preventive Medicine, Emory University School of Medicine (D.K.), Atlanta, Georgia, USA
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10
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Bursic AE, Schell JO, Ernecoff NC, Bansal AD. Delivery of Active Medical Management without Dialysis through an Embedded Kidney Palliative Care Model. Kidney360 2022; 3:1881-1889. [PMID: 36514399 PMCID: PMC9717629 DOI: 10.34067/kid.0001352022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 07/15/2022] [Indexed: 01/12/2023]
Abstract
Background Patients with CKD have high symptom burden, low rates of advance care planning (ACP), and frequently receive care that is not goal concordant. Improved integration of palliative care into nephrology and access to active medical management without dialysis (AMMWD) have the potential to improve outcomes through better symptom management and enhanced shared decision making. Methods We describe the development of a kidney palliative care (KPC) clinic and how palliative care practices are integrated within an academic nephrology clinic. We performed a retrospective electronic health record (EHR) review for patients seen in this clinic between January 2015 and February 2019 to describe key clinical activities and delivery of AMMWD. Results A total of 165 patients were seen in the KPC clinic (139 with CKD and 26 who were already receiving dialysis). Fatigue, mobility issues, and pain were the three most prevalent symptoms (85%, 66%, 58%, respectively). Ninety-one percent of patients had a surrogate decision maker documented in the EHR; 87% of patients had a goals-of-care conversation documented in the EHR. Of the 139 patients with CKD, 67 (48%) chose AMMWD as their disease progressed. Sixty-eight percent (41 of 60) of patients who died during the study were referred to hospice. Conclusions Our findings suggest that the integration of palliative care into nephrology can assist in identification of symptoms, lead to high rates of ACP, and provide a mechanism for patients to choose and receive AMMWD. The percentage of patients choosing AMMWD in our study suggests that increased shared decision making may lower rates of dialysis initiation in the United States. Additional prospective research and registries for assessing the effects of AMMWD have the potential to improve care for people living with CKD.
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Affiliation(s)
- Alexandra E. Bursic
- Renal Electrolyte Division, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jane O. Schell
- Renal Electrolyte Division, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania,Section of Palliative Care and Medical Ethics, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Amar D. Bansal
- Renal Electrolyte Division, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania,Section of Palliative Care and Medical Ethics, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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Eneanya ND, Lakin JR, Paasche-Orlow MK, Lindvall C, Moseley ET, Henault L, Hanchate AD, Mandel EI, Wong SPY, Zupanc SN, Davis AD, El-Jawahri A, Quintiliani LM, Chang Y, Waikar SS, Bansal AD, Schell JO, Lundquist AL, Tamura MK, Yu MK, Unruh ML, Argyropoulos C, Germain MJ, Volandes A. Video Images about Decisions for Ethical Outcomes in Kidney Disease (VIDEO-KD): the study protocol for a multi-centre randomised controlled trial. BMJ Open 2022; 12:e059313. [PMID: 35396311 PMCID: PMC8996022 DOI: 10.1136/bmjopen-2021-059313] [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: 11/11/2022] Open
Abstract
INTRODUCTION Older patients with advanced chronic kidney disease (CKD) often are inadequately prepared to make informed decisions about treatments including dialysis and cardiopulmonary resuscitation. Further, evidence shows that patients with advanced CKD do not commonly engage in advance care planning (ACP), may suffer from poor quality of life, and may be exposed to end-of-life care that is not concordant with their goals. We aim to study the effectiveness of a video intervention on ACP, treatment preferences and other patient-reported outcomes. METHODS AND ANALYSIS The Video Images about Decisions for Ethical Outcomes in Kidney Disease trial is a multi-centre randomised controlled trial that will test the effectiveness of an intervention that includes a CKD-related video decision aid followed by recording personal video declarations about goals of care and treatment preferences in older adults with advancing CKD. We aim to enrol 600 patients over 5 years at 10 sites. ETHICS AND DISSEMINATION Regulatory and ethical aspects of this trial include a single Institutional Review Board mechanism for approval, data use agreements among sites, and a Data Safety and Monitoring Board. We intend to disseminate findings at national meetings and publish our results. TRIAL REGISTRATION NUMBER NCT04347629.
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Affiliation(s)
- Nwamaka D Eneanya
- Renal-Electrolyte and Hypertension Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA, USA
| | - Joshua R Lakin
- Harvard Medical School, Boston, Massachusetts, USA
- Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Michael K Paasche-Orlow
- Boston University School of Medicine, Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Charlotta Lindvall
- Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Edward T Moseley
- Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Lori Henault
- Boston University School of Medicine, Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Amresh D Hanchate
- Department of Social Sciences and Health Policy, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Ernest I Mandel
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Renal (Kidney) Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Susan P Y Wong
- University of Washington, Seattle, Washington State, USA
| | - Sophia N Zupanc
- Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | | | - Areej El-Jawahri
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Lisa M Quintiliani
- Boston University School of Medicine, Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Yuchiao Chang
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sushrut S Waikar
- Section of Nephrology, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts, USA
| | - Amar D Bansal
- Section of Palliative Care and Medical Ethics, Department of General Medicine, 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, Division of Renal-Electrolyte, University of Pittsburgh School of Medicine, UPMC Health System, Pittsburgh, Pennsylvania, USA
| | - Andrew L Lundquist
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Manjula Kurella Tamura
- Division of Nephrology, Stanford University School of Medicine; and Geriatric Research Education Clinical Center, VA Palo Alto Health Care System, Palo Alto, California, USA
| | - Margaret K Yu
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Mark L Unruh
- Department of Medicine, University of New Mexico, Albuquerque, New Mexico, USA
| | - Christos Argyropoulos
- Division of Nephrology, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
| | - Michael J Germain
- Baystate Medical Center-University of Massachusetts Springfield, Springfield, Massachusetts, USA
| | - Angelo Volandes
- Harvard Medical School, Boston, Massachusetts, USA
- ACP Decisions Non-profit Foundation, Newton, Massachusetts, USA
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
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Chiarchiaro J, Arnold RM, Ernecoff NC, Claxton R, Childers JW, Schell JO. Serious Illness Communication Skills Training during a Global Pandemic. ATS Sch 2022; 3:64-75. [PMID: 35634006 PMCID: PMC9131890 DOI: 10.34197/ats-scholar.2021-0074oc] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Accepted: 09/21/2021] [Indexed: 01/05/2023] Open
Abstract
Background Communication skills is a core competency for critical care fellowship training. The coronavirus disease (COVID-19) pandemic has made it increasingly difficult to teach these skills in graduate medical education. We developed and implemented a novel, hybrid version of the Critical Care Communication (C3) skills with virtual and in-person components for pulmonary and critical care fellows. Objective To develop and implement a new hybrid virtual/in-person version of the traditional C3 serious illness communication skills course and to compare learner outcomes to prior courses. Methods We modified the C3 course in 2020 in response to the COVID-19 pandemic by adapting large-group didactic content to an online format that included both virtual asynchronous and virtual live content. Small-group skills training remained in person with trained actors and facilitators. We administered self-assessments to the participants and compared with historical data from the traditional in-person courses beginning in 2012. After the 2020 course, we collected informal feedback from a portion of the learners. Results Like the traditional in-person version, participants rated the hybrid version highly. Learners reported feeling well prepared or very well prepared over 90% of the time in most communication skills after both versions of the course. Over 90% of participants in both versions of the course rated the specific course components as effective or very effective. Feedback from the learners indicates that they prefer the virtual didactics over traditional in-person didactics. Conclusions Pulmonary and critical care fellows rated a hybrid version of a communication skills training similarly to the traditional in-person version of the course. We have provided a scaffolding on how to implement such a course. We anticipate some of the virtual components of this training will outlive the current pandemic based on learner feedback.
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Affiliation(s)
- Jared Chiarchiaro
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Oregon Health Science University, Portland, Oregon; and
| | | | - Natalie C. Ernecoff
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Rene Claxton
- Section of Palliative Care and Medical Ethics, and
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13
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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14
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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15
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Affiliation(s)
- Tessie W October
- Department of Critical Care, Children's National Hospital, Washington, DC, USA.,Department of Pediatrics, School of Medicine and Health Sciences, The George Washington University, Washington, DC, USA
| | - Jane O Schell
- Division of Renal-Electrolyte, University of Pittsburgh School of Medicine, UPMC Health System, Pittsburgh, Pennsylvania, USA.,Division of General Internal Medicine, Section of Palliative Care and Medical Ethics and Palliative Research Center (PaRC), University of Pittsburgh, Pennsylvania, USA
| | - Robert M Arnold
- Division of General Internal Medicine, Section of Palliative Care and Medical Ethics and Palliative Research Center (PaRC), University of Pittsburgh, Pennsylvania, USA
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16
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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17
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Affiliation(s)
- Jane O Schell
- Department of General Medicine, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania
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18
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Affiliation(s)
- Jane O. Schell
- Section of Palliative Care and Medical Ethics, Department of General Medicine, University of Pittsburgh School of Medicine, UPMC Health System, Pittsburgh, Pennsylvania,Division of Renal-Electrolyte, University of Pittsburgh School of Medicine, UPMC Health System, Pittsburgh, Pennsylvania
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Lu E, Schell JO, Koncicki HM. Opioid Management in CKD. Am J Kidney Dis 2021; 77:786-795. [PMID: 33500128 DOI: 10.1053/j.ajkd.2020.08.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 08/23/2020] [Indexed: 11/11/2022]
Abstract
Patients with chronic kidney disease (CKD) experience a high pain and symptom burden. Concurrently, opioid prescription and use in patients with CKD continues to increase, leading to concern for opioid-related risks. Nephrologists increasingly face challenging clinical situations requiring further evaluation and treatment of pain, for which opioid use may be indicated. However, nephrologists are not commonly trained in pain management and may find it difficult to compile the necessary information and tools to effectively assess and treat potentially multidimensional pain. In these situations, they may benefit from using an evidence-based stepwise approach proposed in this article. We address current approaches to opioid use for pain management in CKD and offer a stepwise approach to individualized opioid assessment, focusing on kidney-specific concerns. This includes thorough evaluation of the pain experience, opioid use history, and treatment goals. We subsequently discuss considerations when initiating opioid therapy, strategies to reduce opioid-related risks, and recommended best practices for opioid stewardship in CKD. Using this sequential approach to opioid management, nephrologists can thereby gain a broad overview of key patient considerations, the foundation for understanding implications of opioid use, and a patient-tailored plan for opioid therapy.
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Affiliation(s)
- Emily Lu
- Division of Nephrology and Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY.
| | - Jane O Schell
- Section of Palliative Care and Medical Ethics, Division of Renal-Electrolyte, Department of General Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Holly M Koncicki
- Division of Nephrology and Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
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20
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Cheung KL, Schell JO, Rubin A, Hoops J, Gilmartin B, Cohen RA. Communication Skills Training for Nurses and Social Workers: An Initiative to Promote Interdisciplinary Advance Care Planning and Palliative Care in Patients on Dialysis. Nephrol Nurs J 2021. [DOI: 10.37526/1526-744x.2021.48.6.547] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Cheung KL, Schell JO, Rubin A, Hoops J, Gilmartin B, Cohen RA. Communication Skills Training for Nurses and Social Workers: An Initiative to Promote Interdisciplinary Advance Care Planning and Palliative Care in Patients on Dialysis. Nephrol Nurs J 2021; 48:547-552. [PMID: 34935332 PMCID: PMC9936385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Palliative care initiatives are needed in nephrology, yet implementation is lacking. We created a 6-hour workshop to teach the skills of active listening, responding to emotion, and exploring goals and values to nurses and social workers working in dialysis units. The workshop consisted of interactive didactics and structured role play with trained simulated patients. We assessed preparedness using a Likert scale and utilized paired t tests to measure the impact using a self-assessment survey following the training. Ten nurses and two social workers from six dialysis units completed the training. Mean scores improved in all domains: demonstrating empathic behaviors, responding to emotion and end-of-life concerns, eliciting family's concerns at end-of-life and patient's goals, and discussing spiritual concerns. Further testing in larger samples may help to confirm these results.
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Affiliation(s)
| | - Jane O. Schell
- University of Pittsburgh School of Medicine, Department of General Medicine, Section of Palliative Care and Medical Ethics and the Division of Renal-Electrolyte, Pittsburgh, PA
| | - Alan Rubin
- Division of General Internal Medicine, The University of Vermont Larner College of Medicine, Burlington, VT
| | - Jacqueline Hoops
- The University of Vermont Medical Center, Burlington, VT, and is currently working as a Dialysis RN at Dialysis Clinic Inc., Troy, NY
| | - Bette Gilmartin
- The University of Vermont Medical Center, Burlington, VT, and is currently a Quality Advisor at Cape Cod Hospital, Hyannis, MA
| | - Robert A. Cohen
- Harvard Medical School, and in the Nephrology Division, Beth Israel Deaconess Medical Center, Boston, MA
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22
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Eneanya ND, Percy SG, Stallings TL, Wang W, Steele DJR, Germain MJ, Schell JO, Paasche-Orlow MK, Volandes AE. Use of a Supportive Kidney Care Video Decision Aid in Older Patients: A Randomized Controlled Trial. Am J Nephrol 2020; 51:736-744. [PMID: 32791499 DOI: 10.1159/000509711] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 06/24/2020] [Indexed: 01/02/2023]
Abstract
BACKGROUND There are few studies of patient-facing decision aids that include supportive kidney care as an option. We tested the efficacy of a video decision aid on knowledge of supportive kidney care among older patients with advanced CKD. METHODS Participants (age ≥ 65 years with advanced CKD) were randomized to receive verbal or video education. Primary outcome was knowledge of supportive kidney care (score range 0-3). Secondary outcomes included preference for supportive kidney care, and satisfaction and acceptability of the video. RESULTS Among all participants (n = 100), knowledge of supportive kidney care increased significantly after receiving education (p < 0.01); however, there was no difference between study arms (p = 0.68). There was no difference in preference for supportive kidney care between study arms (p = 0.49). In adjusted analyses, total health literacy score (aOR 1.08 [95% CI: 1.003-1.165]) and nephrologists' answer of "No" to the Surprise Question (aOR 4.87 [95% CI: 1.22-19.43]) were associated with preference for supportive kidney care. Most felt comfortable watching the video (96%), felt the content was helpful (96%), and would recommend the video to others (96%). CONCLUSIONS Among older patients with advanced CKD, we did not detect a significant difference between an educational verbal script and a video decision aid in improving knowledge of supportive kidney care or preferences. However, patients who received video education reported high satisfaction and acceptability ratings. Future research will determine the effectiveness of a supportive kidney care video decision aid on real-world patient outcomes. TRIAL REGISTRATION NCT02698722 (ClinicalTrials.gov).
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Affiliation(s)
- Nwamaka D Eneanya
- Renal-Electrolyte Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA,
- Palliative and Advanced Illness Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA,
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA,
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA,
| | - Shananssa G Percy
- Division of Nephrology, Department of Internal Medicine, Massachusetts General Hospital, Harvard Medical School Center, Boston, Massachusetts, USA
| | - Taylor L Stallings
- Palliative and Advanced Illness Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Wei Wang
- Palliative and Advanced Illness Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David J R Steele
- Division of Nephrology, Department of Internal Medicine, Massachusetts General Hospital, Harvard Medical School Center, Boston, Massachusetts, USA
| | - Michael J Germain
- Division of Nephrology, Baystate Medical Center, University of Massachusetts Medical School - Baystate, Springfield, Massachusetts, USA
| | - Jane O Schell
- Division of Renal-Electrolyte, Department of General Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Michael K Paasche-Orlow
- Section of General Internal Medicine, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Angelo E Volandes
- Division of General Medicine, Department of Internal Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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23
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Lam DY, Scherer JS, Brown M, Grubbs V, Schell JO. A Conceptual Framework of Palliative Care across the Continuum of Advanced Kidney Disease. Clin J Am Soc Nephrol 2019; 14:635-641. [PMID: 30728167 PMCID: PMC6450347 DOI: 10.2215/cjn.09330818] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Kidney palliative care is a growing discipline within nephrology. Kidney palliative care specifically addresses the stress and burden of advanced kidney disease through the provision of expert symptom management, caregiver support, and advance care planning with the goal of optimizing quality of life for patients and families. The integration of palliative care principles is necessary to address the multidimensional impact of advanced kidney disease on patients. In particular, patients with advanced kidney disease have a high symptom burden and experience greater intensity of care at the end of life compared with other chronic serious illnesses. Currently, access to kidney palliative care is lacking, whether delivered by trained kidney care professionals or by palliative care clinicians. These barriers include a gap in training and workforce, policies limiting access to hospice and outpatient palliative care services for patients with ESKD, resistance to integrating palliative care within the nephrology community, and the misconception that palliative care is synonymous with end-of-life care. As such, addressing kidney palliative care needs on a population level will require not only access to specialized kidney palliative care initiatives, but also equipping kidney care professionals with the skills to address basic kidney palliative care needs. This article will address the role of kidney palliative care for patients with advanced kidney disease, describe models of care including primary and specialty kidney palliative care, and outline strategies to improve kidney palliative care on a provider and system level.
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Affiliation(s)
- Daniel Y Lam
- Division of Nephrology, Department of Medicine, Harborview Medical Center, University of Washington, Seattle, Washington;
| | - Jennifer S Scherer
- Division of Palliative Care and Division of Nephrology, Department of Medicine, New York University Langone Health, New York, New York
| | - Mark Brown
- Division of Medicine, St. George Hospital and University of New South Wales, Sydney, Australia
| | - Vanessa Grubbs
- University of California, San Francisco, California.,Division of Nephrology, Department of Medicine, Zuckerberg San Francisco General Hospital, San Francisco, California; and
| | - Jane O Schell
- Division of Renal-Electrolyte, Department of General Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania
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Bansal AD, Schell JO. Strategies to address clinician hesitancy toward conservative care. Nephrol Dial Transplant 2018; 34:5203406. [PMID: 30476344 DOI: 10.1093/ndt/gfy339] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 09/17/2018] [Indexed: 12/14/2022] Open
Affiliation(s)
- Amar D Bansal
- Renal Electrolyte Division, Section of Palliative Care and Medical Ethics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Jane O Schell
- Renal Electrolyte Division, Section of Palliative Care and Medical Ethics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Schell JO, Cohen RA, Green JA, Rubio D, Childers JW, Claxton R, Jeong K, Arnold RM. NephroTalk: Evaluation of a Palliative Care Communication Curriculum for Nephrology Fellows. J Pain Symptom Manage 2018; 56:767-773.e2. [PMID: 30118758 DOI: 10.1016/j.jpainsymman.2018.08.002] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 08/01/2018] [Accepted: 08/02/2018] [Indexed: 02/05/2023]
Abstract
CONTEXT Nephrologists care for a medically complex population that faces difficult decisions around treatment options and end-of-life care. Yet communication training within nephrology fellowship is rare. Prior work suggests that communication training in nephrology can improve perceived preparedness to engage in difficult conversations; however, it is unclear if this training results in improved clinical skills. OBJECTIVES The primary aim was to evaluate the efficacy of a three-day curriculum for nephrology fellows (NephroTalk) to improve communication skill acquisition for delivering serious news. We also measured self-reported preparedness for three additional communication tasks taught, including goals of care and transitions at end of life. METHODS Thirty-three first- and second-year fellows from seven academic nephrology programs participated in NephroTalk from 2015 to 2016. Pretraining and post-training encounters to deliver bad news with standardized patients were audiorecorded and evaluated using a modified communication checklist. Fellow experience and self-reported improvement in communication tasks were measured using a five-point Likert scale. RESULTS Skill use increased after training for seven of the nine skills measured (P < 0.01). The average number of skills gained after training was 3.6 ± 1.8 skills. With increased communication proficiency, post-training encounters were significantly shorter than pretraining encounters (P = 0.03). Fellows reported improved preparedness to engage in all communication tasks taught in NephroTalk curriculum. CONCLUSION Our findings support NephroTalk as an effective communication skills curriculum for nephrology trainees. Fellows increased their communication skills significantly in delivering bad news leading to more efficient encounters.
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Affiliation(s)
- Jane O Schell
- Department of General Medicine, Section of Palliative Care and Medical Ethics, Pittsburgh, Pennsylvania, USA; Division of Renal-Electrolyte, University of Pittsburgh School of Medicine, UPMC Health System, Pittsburgh, Pennsylvania, USA.
| | - Robert A Cohen
- Nephrology Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Jamie A Green
- Kidney Health Research Institute, Geisinger Medical Center, Danville, Pennsylvania, USA
| | - Doris Rubio
- Center for Research on Health Care Data Center, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Julie W Childers
- Department of General Medicine, Section of Palliative Care and Medical Ethics, Pittsburgh, Pennsylvania, USA
| | - Rene Claxton
- Department of General Medicine, Section of Palliative Care and Medical Ethics, Pittsburgh, Pennsylvania, USA
| | - Kwonho Jeong
- Center for Research on Health Care Data Center, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Robert M Arnold
- Department of General Medicine, Section of Palliative Care and Medical Ethics, Pittsburgh, Pennsylvania, USA; Palliative and Supportive Institute, UPMC Health System, Pittsburgh, Pennsylvania, USA
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Tong A, Crews DC, Schell JO, de Boer IH, Chonchol M, Mehrotra R. Young Kidney Professionals' Perspectives and Attitudes about Consuming Scientific Information: A Focus Group Study. Clin J Am Soc Nephrol 2018; 13:1587-1597. [PMID: 30143529 PMCID: PMC6218813 DOI: 10.2215/cjn.01760218] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The digital era has seen rapid changes in how information is consumed. Traditional dissemination of scholarly work through biomedical journals may not be optimally tailored to the preferences of younger clinicians and researchers. We aimed to describe the perspectives of young clinicians and researchers in kidney disease on consuming scientific information. Three focus groups were conducted during the 2017 American Society of Nephrology Kidney Week with a total of 29 nephrologists and researchers (ages 40 years old and younger) purposively sampled through our networks and the American Society of Nephrology registration database. Data were analyzed thematically. Of the 72 participants invited, 29 participated from 28 centers across 13 countries. Five themes were identified: capturing and retaining attention (with subthemes of triggering interest, optimizing readability, and navigation to sustain motivation); having discernible relevance (resonating with clinical and research interests, supporting professional development, action-oriented and readily applicable, able to disseminate, contextualizing the study, and filtering out informational noise); immediacy and efficiency in processing information (requiring instantaneous and easy access, enabling rapid understanding, and facilitating comprehension of complex concepts); trusting legitimate and credible sources (authoritative indicator of importance and quality, reputable experts broadening perspective, certainty and confidence with collegial input, accurate framing and translation of the message, ascertaining methodologic detail and nuances, and integrating the patient perspective); and social dialoguing and debate. Immediate and digitally optimized access motivated young kidney professionals to consume scientific information. Mechanisms that enable them to distil relevant and new evidence, appraise and apply information to clinical practice and research, disseminate studies to colleagues, and engage in discussion and debate may enhance their comprehension, confidence, interpretation, and use of scientific literature.
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Affiliation(s)
- Allison Tong
- Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia
- Centre for Kidney Research, The Children’s Hospital at Westmead, Sydney, New South Wales, Australia
| | - Deidra C. Crews
- Division of Nephrology, Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Jane O. Schell
- Division of Renal-Electrolyte, Section of Palliative Care and Medical Ethics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Ian H. de Boer
- Division of Nephrology, Kidney Research Institute and Harborview Medical Center, University of Washington, Seattle, Washington; and
| | - Michel Chonchol
- Division of Renal Diseases and Hypertension, University of Colorado, Aurora, Colorado
| | - Rajnish Mehrotra
- Division of Nephrology, Kidney Research Institute and Harborview Medical Center, University of Washington, Seattle, Washington; and
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Affiliation(s)
- Jane O. Schell
- Section of Palliative Care and Medical Ethics, Department of General Medicine, and
- Division of Renal-Electrolyte, University of Pittsburgh School of Medicine, UPMC Health System, Pittsburgh, Pennsylvania; and
| | - Robert A. Cohen
- Nephrology Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Bansal AD, Leonberg-Yoo A, Schell JO, Scherer JS, Jones CA. Ten Tips Nephrologists Wish the Palliative Care Team Knew About Caring for Patients with Kidney Disease. J Palliat Med 2018; 21:546-551. [DOI: 10.1089/jpm.2018.0087] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Affiliation(s)
- Amar D. Bansal
- Section of Palliative Care and Medical Ethics, Renal-Electrolyte Division, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Amanda Leonberg-Yoo
- Division of Nephrology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jane O. Schell
- Section of Palliative Care and Medical Ethics, Renal-Electrolyte Division, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jennifer S. Scherer
- Division of Palliative Care and Nephrology, New York University School of Medicine, New York, New York
| | - Christopher A. Jones
- Perelman School of Medicine and Palliative and Advanced Illness Research Center, University of Pennsylvania, Philadelphia, Pennsylvania
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Abstract
Most patients who rely on dialysis for treatment of end-stage renal disease (ESRD) never receive a kidney transplant. Therefore, it is important for nephrology providers to feel comfortable discussing the role of dialysis near the end of life (EOL). Advance care planning (ACP) is an ongoing process of learning patient values and goals in an effort to outline preferences for current and future care. This review presents a framework for how to incorporate ACP in the care of dialysis patients throughout the kidney disease course and at the EOL. Early ACP is useful for all dialysis patients and should ideally begin in the absence of clinical setbacks. Check-in conversations can be used to continue longitudinal discussions with patients and identify opportunities for symptom management and support. Lastly, triggered ACP is useful to clarify care preferences for patients with worsening clinical status. Practical tools include prognostication models to identify patients at risk for decline; ACP documents to operationalize patient care preferences; and communication guidance for engaging in these important conversations. Interdisciplinary teams with expertise from social work, palliative care, and hospice can be helpful at various stages and are discussed here.
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Affiliation(s)
- Amar D Bansal
- Section of Palliative Care and Medical Ethics, Renal-Electrolyte Division, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Jane O Schell
- Section of Palliative Care and Medical Ethics, Renal-Electrolyte Division, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Affiliation(s)
- Amar D Bansal
- Division of Renal-Electrolyte, Section of Palliative Care and Medical Ethics, Department of General Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Affiliation(s)
- Jane O Schell
- University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
| | - Daniel Lam
- Harborview Medical Center, University of Washington, Seattle, Washington
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Koncicki HM, Unruh M, Schell JO. In Reply to 'Opioid Overuse or NSAID Underuse? A Response to the Pain Guide'. Am J Kidney Dis 2017; 69:865-866. [PMID: 28454685 DOI: 10.1053/j.ajkd.2017.03.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 03/20/2017] [Indexed: 11/11/2022]
Affiliation(s)
| | - Mark Unruh
- New Mexico Veteran's Hospital, Albuquerque, New Mexico; Raymond G. Murphy VA Medical Center, Albuquerque, New Mexico; University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Jane O Schell
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Pinter J, Hanson CS, Chapman JR, Wong G, Craig JC, Schell JO, Tong A. Perspectives of Older Kidney Transplant Recipients on Kidney Transplantation. Clin J Am Soc Nephrol 2017; 12:443-453. [PMID: 28143863 PMCID: PMC5338704 DOI: 10.2215/cjn.05890616] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2016] [Accepted: 11/02/2016] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Older kidney transplant recipients are susceptible to cognitive impairment, frailty, comorbidities, immunosuppression-related complications, and chronic graft failure, however, there has been limited focus on their concerns and expectations related to transplantation. This study aims to describe the perspectives of older kidney transplant recipients about their experience of kidney transplantation, self-management, and treatment goals to inform strategies and interventions that address their specific needs. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Face-to-face semistructured interviews were conducted with 30 kidney transplant recipients aged 65-80 years from five renal units in Australia. Transcripts were analyzed thematically. RESULTS Six themes were identified: restoring vitality of youth (with subthemes of revived mindset for resilience, embracing enjoyment in life, drive for self-actualization); persisting through prolonged recovery (yielding to aging, accepting functional limitations, pushing the limit, enduring treatment responsibilities); imposing sicknesses (combatting devastating comorbidities, painful restrictions, emerging disillusionment, anxieties about accumulating side effects, consuming treatment burden); prioritizing graft survival (privileged with a miracle, negotiating risks for longevity, enacting a moral duty, preserving the last opportunity); confronting health deterioration (vulnerability and helplessness, narrowing focus to immediate concerns, uncertainty of survival); and value of existence (purpose through autonomy, refusing the burden of futile treatment, staying alive by all means). CONCLUSIONS Older kidney transplant recipients felt able to enjoy life and strived to live at their newly re-established potential and capability, which motivated them to protect their graft. However, some felt constrained by slow recuperation and overwhelmed by unexpected comorbidities, medication-related side effects, and health decline. Our findings suggest the need to prepare and support older recipients for self-management responsibilities, clarify their expectations of post-transplant risks and outcomes, and provide assistance through prolonged recovery after kidney transplantation.
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Affiliation(s)
- Jule Pinter
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Centre for Kidney Research, The Children’s Hospital at Westmead, Westmead, New South Wales, Australia
- Department of Medicine, Division of Nephrology, Würzburg University Clinic, Würzburg, Germany
| | - Camilla S. Hanson
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Centre for Kidney Research, The Children’s Hospital at Westmead, Westmead, New South Wales, Australia
| | - Jeremy R. Chapman
- Centre for Transplant and Renal Research, Westmead Hospital, Westmead, New South Wales, Australia; and
| | - Germaine Wong
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Centre for Kidney Research, The Children’s Hospital at Westmead, Westmead, New South Wales, Australia
- Centre for Transplant and Renal Research, Westmead Hospital, Westmead, New South Wales, Australia; and
| | - Jonathan C. Craig
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Centre for Kidney Research, The Children’s Hospital at Westmead, Westmead, New South Wales, Australia
| | - Jane O. Schell
- Section of Palliative Care and Medical Ethics, Renal-Electrolyte Division, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Allison Tong
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Centre for Kidney Research, The Children’s Hospital at Westmead, Westmead, New South Wales, Australia
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Koncicki HM, Unruh M, Schell JO. Pain Management in CKD: A Guide for Nephrology Providers. Am J Kidney Dis 2017; 69:451-460. [DOI: 10.1053/j.ajkd.2016.08.039] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Accepted: 08/09/2016] [Indexed: 02/05/2023]
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Javier AD, Figueroa R, Siew ED, Salat H, Morse J, Stewart TG, Malhotra R, Jhamb M, Schell JO, Cardona CY, Maxwell CA, Ikizler TA, Abdel-Kader K. Reliability and Utility of the Surprise Question in CKD Stages 4 to 5. Am J Kidney Dis 2017; 70:93-101. [PMID: 28215946 DOI: 10.1053/j.ajkd.2016.11.025] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Accepted: 11/20/2016] [Indexed: 12/25/2022]
Abstract
BACKGROUND Prognostic uncertainty is one barrier to engaging in goals-of-care discussions in chronic kidney disease (CKD). The surprise question ("Would you be surprised if this patient died in the next 12 months?") is a tool to assist in prognostication. However, it has not been studied in non-dialysis-dependent CKD and its reliability is unknown. STUDY DESIGN Observational study. SETTING & PARTICIPANTS 388 patients at least 60 years of age with non-dialysis-dependent CKD stages 4 to 5 who were seen at an outpatient nephrology clinic. PREDICTOR Trinary (ie, Yes, Neutral, or No) and binary (Yes or No) surprise question response. OUTCOMES Mortality, test-retest reliability, and blinded inter-rater reliability. MEASUREMENTS Baseline comorbid conditions, Charlson Comorbidity Index, cause of CKD, and baseline laboratory values (ie, serum creatinine/estimated glomerular filtration rate, serum albumin, and hemoglobin). RESULTS Median patient age was 71 years with median follow-up of 1.4 years, during which time 52 (13%) patients died. Using the trinary surprise question, providers responded Yes, Neutral, and No for 202 (52%), 80 (21%), and 106 (27%) patients, respectively. About 5%, 15%, and 27% of Yes, Neutral, and No patients died, respectively (P<0.001). Trinary surprise question inter-rater reliability was 0.58 (95% CI, 0.42-0.72), and test-retest reliability was 0.63 (95% CI, 0.54-0.72). The trinary surprise question No response had sensitivity and specificity of 55% and 76%, respectively (95% CIs, 38%-71% and 71%-80%, respectively). The binary surprise question had sensitivity of 66% (95% CI, 49%-80%; P=0.3 vs trinary), but lower specificity of 68% (95% CI, 63%-73%; P=0.02 vs trinary). LIMITATIONS Single center, small number of deaths. CONCLUSIONS The surprise question associates with mortality in CKD stages 4 to 5 and demonstrates moderate to good reliability. Future studies should examine how best to deploy the surprise question to facilitate advance care planning in advanced non-dialysis-dependent CKD.
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Affiliation(s)
- Andrei D Javier
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN; Vanderbilt Center for Kidney Disease, Nashville, TN
| | - Rocio Figueroa
- Division of Nephrology, University of New Mexico, Albuquerque, NM
| | - Edward D Siew
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN; Vanderbilt Center for Kidney Disease, Nashville, TN
| | - Huzaifah Salat
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN; Vanderbilt Center for Kidney Disease, Nashville, TN
| | - Jennifer Morse
- Department of Biostatistics, Vanderbilt University, Nashville, TN
| | - Thomas G Stewart
- Department of Biostatistics, Vanderbilt University, Nashville, TN
| | - Rakesh Malhotra
- Division of Nephrology, University of California at San Diego, San Diego, CA
| | - Manisha Jhamb
- Renal-Electrolyte Division, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Jane O Schell
- Renal-Electrolyte Division, University of Pittsburgh School of Medicine, Pittsburgh, PA; Section of Palliative Care and Medical Ethics, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Cesar Y Cardona
- Division of Nephrology, Meharry Medical College, Nashville, TN
| | | | - T Alp Ikizler
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN; Vanderbilt Center for Kidney Disease, Nashville, TN
| | - Khaled Abdel-Kader
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN; Vanderbilt Center for Kidney Disease, Nashville, TN.
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Brown EA, Bekker HL, Davison SN, Koffman J, Schell JO. Supportive Care: Communication Strategies to Improve Cultural Competence in Shared Decision Making. Clin J Am Soc Nephrol 2016; 11:1902-1908. [PMID: 27510456 PMCID: PMC5053803 DOI: 10.2215/cjn.13661215] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Historic migration and the ever-increasing current migration into Western countries have greatly changed the ethnic and cultural patterns of patient populations. Because health care beliefs of minority groups may follow their religion and country of origin, inevitable conflict can arise with decision making at the end of life. The principles of truth telling and patient autonomy are embedded in the framework of Anglo-American medical ethics. In contrast, in many parts of the world, the cultural norm is protection of the patient from the truth, decision making by the family, and a tradition of familial piety, where it is dishonorable not to do as much as possible for parents. The challenge for health care professionals is to understand how culture has enormous potential to influence patients' responses to medical issues, such as healing and suffering, as well as the physician-patient relationship. Our paper provides a framework of communication strategies that enhance crosscultural competency within nephrology teams. Shared decision making also enables clinicians to be culturally competent communicators by providing a model where clinicians and patients jointly consider best clinical evidence in light of a patient's specific health characteristics and values when choosing health care. The development of decision aids to include cultural awareness could avoid conflict proactively, more productively address it when it occurs, and enable decision making within the framework of the patient and family cultural beliefs.
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Affiliation(s)
- Edwina A. Brown
- Imperial College Renal and Transplant Centre, Hammersmith Hospital, London, United Kingdom
| | - Hilary L. Bekker
- Leeds Institute of Health Sciences, School of Medicine, University of Leeds, Leeds, United Kingdom
| | - Sara N. Davison
- Division of Nephrology and Immunology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Jonathan Koffman
- Department of Palliative Care, Policy and Rehabilitation, Cicely Saunders Institute, King’s College London, London, United Kingdom; and
| | - Jane O. Schell
- Section of Palliative Care and Medical Ethics, Renal-Electrolyte Division, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Hall RK, Haines C, Gorbatkin SM, Schlanger L, Shaban H, Schell JO, Gurley SB, Colón-Emeric CS, Bowling CB. Incorporating Geriatric Assessment into a Nephrology Clinic: Preliminary Data from Two Models of Care. J Am Geriatr Soc 2016; 64:2154-2158. [PMID: 27377350 PMCID: PMC5073016 DOI: 10.1111/jgs.14262] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Older adults with advanced chronic kidney disease (CKD) experience functional impairment that can complicate CKD management. Failure to recognize functional impairment may put these individuals at risk of further functional decline, nursing home placement, and missed opportunities for timely goals-of-care conversations. Routine geriatric assessment could be a useful tool for identifying older adults with CKD who are at risk of functional decline and provide contextual information to guide clinical decision-making. Two innovative programs were implemented in the Veterans Health Administration that incorporate geriatric assessment into a nephrology visit. In one program, a geriatrician embedded in a nephrology clinic used standardized geriatric assessment tools with individuals with CKD aged 70 and older (Comprehensive Geriatric Assessment for CKD) (CGA-4-CKD). In the second program, a nephrology clinic used comprehensive appointments for individuals aged 75 and older to conduct geriatric assessments and CKD care (Renal Silver). Data on 68 veterans who had geriatric assessments through these programs between November 2013 and May 2015 are reported. In CGA-4-CKD, difficulty with one or more activities of daily living (ADLs), history of falls, and cognitive impairment were each found in 27.3% of participants. ADL difficulty was found in 65.7%, falls in 28.6%, and cognitive impairment in 51.6% of participants in Renal Silver. Geriatric assessment guided care processes in 45.4% (n = 15) of veterans in the CGA-4-CKD program and 37.1% (n = 13) of those in Renal Silver. Findings suggest there is a significant burden of functional impairment in older adults with CKD. Knowledge of this impairment is applicable to CKD management.
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Affiliation(s)
- Rasheeda K Hall
- Geriatric Research, Education and Clinical Center, Durham Veterans Affairs Medical Center, Durham, North Carolina.
- Renal Section, Durham Veterans Affairs Medical Center, Durham, North Carolina.
- Department of Medicine, Duke University Medical Center, Durham, North Carolina.
| | - Carol Haines
- Renal Section, Durham Veterans Affairs Medical Center, Durham, North Carolina
| | - Steven M Gorbatkin
- Nephrology Service, Atlanta Veterans Affairs Medical Center, Decatur, Georgia
- Department of Medicine, Emory University, Atlanta, Georgia
| | - Lynn Schlanger
- Nephrology Service, Atlanta Veterans Affairs Medical Center, Decatur, Georgia
- Department of Medicine, Emory University, Atlanta, Georgia
| | - Hesham Shaban
- Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Jane O Schell
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Susan B Gurley
- Renal Section, Durham Veterans Affairs Medical Center, Durham, North Carolina
- Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Cathleen S Colón-Emeric
- Geriatric Research, Education and Clinical Center, Durham Veterans Affairs Medical Center, Durham, North Carolina
- Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - C Barrett Bowling
- Department of Medicine, Emory University, Atlanta, Georgia
- Geriatric Research, Education and Clinical Center, Birmingham/Atlanta Veterans Affairs Medical Center, Decatur, Georgia
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Cohen RA, Jackson VA, Norwich D, Schell JO, Schaefer K, Ship AN, Sullivan AM. A Nephrology Fellows' Communication Skills Course: An Educational Quality Improvement Report. Am J Kidney Dis 2016; 68:203-211. [PMID: 26994686 DOI: 10.1053/j.ajkd.2016.01.025] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Accepted: 01/24/2016] [Indexed: 11/11/2022]
Abstract
BACKGROUND Nephrology fellows need expertise navigating challenging conversations with patients throughout the course of advanced kidney disease. However, evidence shows that nephrologists receive inadequate training in this area. This study assessed the effectiveness of an educational quality improvement intervention designed to enhance fellows' communication with patients who have advanced kidney disease. STUDY DESIGN Quality improvement project. SETTING & PARTICIPANTS Full-day annual workshops (2013-2014) using didactics, discussion, and practice with simulated patients. Content focused on delivering bad news, acknowledging emotion, discussing care goals in dialysis decision making when prognosis is uncertain, and addressing dialysis therapy withdrawal and end of life. Participants were first-year nephrology fellows from 2 Harvard-affiliated training programs (N=26). QUALITY IMPROVEMENT PLAN Study assessed the effectiveness of an intervention designed to enhance fellows' communication skills. OUTCOMES Primary outcomes were changes in self-reported patient communication skills, attitudes, and behaviors related to discussing disease progression, prognostic uncertainty, dialysis therapy withdrawal, treatments not indicated, and end of life; responding to emotion; eliciting patient goals and values; and incorporating patient goals into recommendations. MEASUREMENTS Surveys measured prior training, pre- and postcourse perceived changes in skills and values, and reported longer term (3-month) changes in communication behaviors, using both closed- and open-ended items. RESULTS Response rates were 100% (pre- and postsurveys) and 68% (follow-up). Participants reported improvement in all domains, with an overall mean increase of 1.1 (summed average scores: precourse, 2.8; postcourse, 3.9 [1-5 scale; 5 = "extremely well prepared"]; P<0.001), with improvement sustained at 3 months. Participants reported meaningful changes integrating into practice specific skills taught, such as "Ask-Tell-Ask" and using open-ended questions. LIMITATIONS Self-reported data may overestimate actual changes; small sample size and the programs' affiliation with a single medical school may limit generalizability. CONCLUSIONS A day-long course addressing nephrology fellows' communication competencies across the full course of patients' illness experience can enhance fellows' self-reported skills and practices.
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Affiliation(s)
- Robert A Cohen
- Nephrology Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
| | - Vicki A Jackson
- Palliative Care Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Diana Norwich
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Jane O Schell
- Section of Palliative Care and Medical Ethics and Renal Division-Electrolyte Division, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Kristen Schaefer
- Division of Psychosocial Medicine and Palliative Care, Dana Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Amy N Ship
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Amy M Sullivan
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
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Koncicki HM, Schell JO. Communication Skills and Decision Making for Elderly Patients With Advanced Kidney Disease: A Guide for Nephrologists. Am J Kidney Dis 2015; 67:688-95. [PMID: 26709108 DOI: 10.1053/j.ajkd.2015.09.032] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Accepted: 09/18/2015] [Indexed: 11/11/2022]
Abstract
Elderly patients comprise the most rapidly growing population initiating dialysis therapy and may derive particular benefit from comprehensive assessment of geriatric syndromes, coexisting comorbid conditions, and overall prognosis. Palliative care is a philosophy that aims to improve quality of life and assist with treatment decision making for patients with serious illness such as kidney disease. Palliative skills for the nephrology provider can aid in the care of these patients. This review provides nephrology providers with 4 primary palliative care skills to guide treatment decision making: (1) use prognostic tools to identify patients who may benefit from conservative management, (2) disclose prognostic information to patients who may not do well with dialysis therapy, (3) incorporate patient goals and values to outline a treatment plan, and (4) prepare patients and families for transitions and end of life.
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Affiliation(s)
- Holly M Koncicki
- Division of Kidney Diseases and Hypertension, Hofstra North Shore-LIJ School of Medicine, North Shore LIJ Health Systems, Great Neck, NY.
| | - Jane O Schell
- Section of Palliative Care and Medical Ethics, Renal-Electrolyte Division, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
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Schell JO, Bova-Collis R, Eneanya ND. An interdisciplinary approach to dialysis decision-making in the CKD patient with depression. Adv Chronic Kidney Dis 2014; 21:385-91. [PMID: 24969392 DOI: 10.1053/j.ackd.2014.03.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2014] [Revised: 03/14/2014] [Accepted: 03/17/2014] [Indexed: 11/11/2022]
Abstract
Depression and depressive symptoms are common in advanced kidney disease and are associated with poor outcomes. For those with CKD not on dialysis, depression may influence how patients cope and prepare for their disease and its management, including decisions about dialysis treatment. Patient self-reported scales exist to better identify depression; how to incorporate these scales into clinical practice and assist with treatment decision-making is less clear. We present a case-based discussion of depressive symptoms in patients with advanced kidney disease not on dialysis. We highlight the contribution of underlying somatic and psychosocial factors in the assessment and management of depression. We further define the role of the interdisciplinary care team, including palliative care and hospice medicine, to assist with symptom management and end-of-life care for CKD patients with depression.
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Abstract
Frail elderly patients with advanced kidney disease experience many of the burdens associated with dialysis. Although these patients constitute the fastest-growing population starting dialysis, they often suffer loss of functional status, impaired quality of life, and increased mortality after dialysis initiation. Nephrology clinicians face the challenges of helping patients decide if the potential benefits of dialysis outweigh the risks and preparing such patients for future setbacks. A communication framework for dialysis decision-making that aligns treatment choices with patient goals and values is presented. The role of uncertainty is highlighted, and the concept of a goal-directed care plan is introduced. This plan incorporates a time-limited trial that promotes frequent opportunities for reassessment. Using the communication skills presented, the clinician can prepare and guide patients for the dialysis trajectory as it unfolds.
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Affiliation(s)
- Jane O Schell
- Section of Palliative Care and Medical Ethics and Renal-Electrolyte Division, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; and
| | - Robert A Cohen
- Department of Medicine, Nephrology Division, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
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Affiliation(s)
- Jane O. Schell
- Renal-Electrolyte Division; University of Pittsburgh School of Medicine; UPMC; Pittsburgh Pennsylvania
- Section of Palliative Care and Medical Ethics; University of Pittsburgh School of Medicine; UPMC; Pittsburgh Pennsylvania
| | - Robert M. Arnold
- Section of Palliative Care and Medical Ethics; University of Pittsburgh School of Medicine; UPMC; Pittsburgh Pennsylvania
- Palliative and Supportive Institute; University of Pittsburgh School of Medicine; UPMC; Pittsburgh Pennsylvania
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Affiliation(s)
- Jane O Schell
- Section of Palliative Care and Medical Ethics, Renal-Electrolyte Division, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, †Carle Physician Group and University of Illinois, Urbana-Champaign, Urbana, Illinois
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Schell JO, Green JA, Tulsky JA, Arnold RM. Communication skills training for dialysis decision-making and end-of-life care in nephrology. Clin J Am Soc Nephrol 2012; 8:675-80. [PMID: 23143502 DOI: 10.2215/cjn.05220512] [Citation(s) in RCA: 88] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Nephrology fellows often face difficult conversations about dialysis initiation or withdrawal but are frequently unprepared for these discussions. Despite evidence that communication skills are teachable, few fellowship programs include such training. A communication skills workshop for nephrology fellows (NephroTalk) focused on delivering bad news and helping patients define care goals, including end-of-life preferences. This 4-hour workshop, held in October and November 2011, included didactics and practice sessions with standardized patients. Participants were nephrology fellows at Duke University and the University of Pittsburgh (n=22). Pre- and post-workshop surveys evaluated efficacy of the curriculum and measured changes in perceived preparedness on the basis on workshop training. Overall, 14% of fellows were white and 50% were male. Less than one-third (6 of 22) reported prior palliative care training. Survey response rate varied between 86% and 100%. Only 36% (8 of 22) and 38% (8 of 21) of respondents had received structured training in discussions for dialysis initiation or withdrawal. Respondents (19 of 19) felt that communication skills were important to being a "great nephrologist." Mean level of preparedness as measured with a five-point Likert scale significantly increased for all skills (range, 0.5-1.14; P<0.01), including delivering bad news, expressing empathy, and discussing dialysis initiation and withdrawal. All respondents (21 of 21) reported they would recommend this training to other fellows. NephroTalk is successful for improving preparedness among nephrology fellows for having difficult conversations about dialysis decision-making and end-of-life care.
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Affiliation(s)
- Jane O Schell
- Department of Medicine and Center for Palliative Care, Duke University, Durham, North Carolina, USA.
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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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Schell JO, Germain MJ, Finkelstein FO, Tulsky JA, Cohen LM. An integrative approach to advanced kidney disease in the elderly. Adv Chronic Kidney Dis 2010; 17:368-77. [PMID: 20610364 DOI: 10.1053/j.ackd.2010.03.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2009] [Revised: 02/03/2010] [Accepted: 03/09/2010] [Indexed: 12/11/2022]
Abstract
Chronic kidney disease (CKD) has increasingly become a "geriatric" disease, with a dramatic rise in incidence in the aging population. Patients aged >75 years have become the fastest growing population initiating dialysis. These patients have increased comorbid diseases and functional limitations which affect mortality and quality of life. This review describes the challenges of dialysis initiation and considerations for management of the elderly subpopulation. There is a need for an integrative approach to care, which addresses management issues, health-related quality of life, and timely discussion of goals of care and end-of-life issues. This comprehensive approach to patient care involves the integration of nephrology, geriatric, and palliative medicine practices.
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Linfert DR, Schell JO, Fine DM. NSF: WHAT WE KNOW AND WHAT WE NEED TO KNOW: Treatment of Nephrogenic Systemic Fibrosis: Limited Options but Hope for the Future. Semin Dial 2008; 21:155-9. [DOI: 10.1111/j.1525-139x.2007.00407.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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