scholarly journals 49 Introducing A Geriatrician Into A Renal Service to Aid Decision-Making and Advance Care Planning

2020 ◽  
Vol 49 (Supplement_1) ◽  
pp. i14-i17
Author(s):  
V Aylett ◽  
A Mooney ◽  
Z Kime ◽  
A Windass
Keyword(s):  
Advance Care Planning ◽  
Conservative Management ◽  
Older Patients ◽  
Care Plan ◽  
Care Planning ◽  
Care Clinic ◽  
Advance Care ◽  
Stage Renal Disease ◽  
End Stage ◽  
Aid Decision

Abstract Introduction Over the past 30 years the population of end-stage renal disease (ESRD) patients has aged; the average age of starting dialysis is 67. Many have significant comorbidities, and the benefit for frail patients or those over 80 starting dialysis is uncertain. Despite this, when older patients with ESRD are admitted to hospital as an emergency, few have an advance care plan or resuscitation decision. The Nephrologists in our hospital recognised that many of these patients might benefit from an out-patient Geriatrician review. Methods The Renal Low Clearance Clinic in Leeds assesses patients with ESRD who are approaching dialysis or conservative management. A Geriatrician was established within this setting, seeing patients in an alternate-week clinic. A collaborative approach with the pre-dialysis nurses led to identification of appropriate older patients. This work has been described elsewhere (KimeZ et al, abstract accepted for UK Kidney Week 2019.) Use of comprehensive geriatric assessment (CGA) allowed for sensitive exploration of long-term goals, with discussions regarding plans in relation to renal replacement therapy and resuscitation, as well as generating continence, falls and memory clinic referrals. Where possible, family were involved. Results 43 patients had completed encounters, with an average age of 79 (range 67-90.) The median Rockwood Frailty Score was 4 (range 1-7). 29 patients were seen at one visit, the rest requiring 2 or 3 appointments. Prior to the encounter, only 2 patients had a DNACPR decision in place. Following this, 42 patients had had a resuscitation discussion and 18 patients chose DNACPR. Initially, only 7 patients had already chosen conservative management; this increased to 21 following discussions, including 7 who had previously opted for dialysis, the other 7 having been undecided. Those choosing conservative management were referred on to a specialist Renal-Palliative Care clinic. Conclusions Introducing a Geriatrician into the Low Clearance clinic has been welcomed by Renal colleagues and the effect has been apparent, with increasingly challenging patients being referred. CGA and advance care planning is feasible in this setting, which should have beneficial outcomes for patients in the longer term.

scholarly journals Advance care plan barriers in older patients with end-stage renal disease: a qualitative nephrologist interview study

2019 ◽  
Vol 10 (4) ◽  
pp. e39-e39 ◽  
Author(s):  
Julien O'Riordan ◽  
Helen Noble ◽  
P M Kane ◽  
Andrew Smyth
Keyword(s):  
Renal Disease ◽  
End Of Life ◽  
Advance Care Planning ◽  
End Stage Renal Disease ◽  
End Of Life Care ◽  
Older Patients ◽  
Care Planning ◽  
Advance Care ◽  
Stage Renal Disease ◽  
End Stage

ObjectivesOlder patients with end-stage renal disease are willing participants in advance care planning but just over 10% are engaged in this process. Nephrologists fear such conversations may upset patients and so tend to avoid these discussions. This approach denies patients the opportunity to discuss their end-of-life care preferences. Many patients endure medically intensive end-of-life scenarios as a result. This study aims to explore the rationale underpinning nephrologists’ clinical decision-making in the management of older patients with end-stage renal disease and to make recommendations that inform policymakers and enhance advance care planning for this patient group.MethodsA qualitative interview study of 20 nephrologists was undertaken. Nephrologists were asked about their management of end-stage renal disease in older patients, conservative management, dialysis withdrawal and end-of-life care. Eligible participants were nephrologists working in Ireland. Five nephrologists participated in a recorded focus group and 15 nephrologists participated in individual digitally recorded telephone interviews. Semistructured interviews were conducted; thematic analysis was used to distil the results.ResultsThree key themes emerged: barriers to advance care planning; barriers to shared decision-making; and avoidance of end-of-life care discussion.ConclusionsAdvance care planning is not an integral part of the routine care of older patients with end-stage renal disease. Absence of formal training of nephrologists in how to communicate with patients contributes to poor advance care planning. Nephrologists lack clinical experience of conservatively managing end-stage renal disease and end-of-life care in older patients. Key policy recommendations include formal communication skills training for nephrologists and development of the conservative management service.

Prevalence of advance care planning in a resident run clinic in an underserved community.

2021 ◽  
Vol 39 (15_suppl) ◽  
pp. e24067-e24067
Author(s):  
Swetha Ann Alexander ◽  
Vinay Mathew Thomas ◽  
David Wu ◽  
Radhika Kulkarni ◽  
William Rabitaille
Keyword(s):  
Primary Care ◽  
African American ◽  
Advance Care Planning ◽  
Primary Care Clinic ◽  
Retrospective Chart Review ◽  
Care Planning ◽  
Care Clinic ◽  
Underserved Community ◽  
Advance Care ◽  
End Stage

e24067 Background: Advance Care Planning (ACP) ensures that patients receive care that is in line with their values and preferences. ACP is best done in the outpatient setting. Despite recognizing the importance of ACP, the rates of ACP completion continue to be low. We conducted a retrospective study to determine the rates of ACP in a resident run primary care clinic in Hartford, Connecticut, which serves the underserved community. We looked at patient characteristics to find correlation with ACP completion. We also aimed to determine the reasons which could decrease the completion of ACP. Methods: This was a retrospective chart review. Patients who met any of the inclusion criteria [i) Age>65 ii) End stage renal disease on dialysis iii) Metastatic/Recurrent cancer iv) End stage heart failure v) COPD Gold stage D] and were seen in the primary care clinic from September 1, 2019 to December 31, 2019 were selected. Their charts were reviewed to see if ACP was documented during primary care visits over the past two years. The demographics of the patients were noted. Subsequently, a survey was distributed to residents to determine the possible causes of low rates of ACP discussion. Results: The characteristics of the 373 patients included in the study are shown in Table 1. Only 14 (3.8%) of the 373 had documentation of ACP during their primary care visits. The characteristics of the 14 patients in whom ACP was done are as follows: Sex- Female 9/14 (64%); Ethnicity- Hispanic 10/14 (71%), African American 4/14 (29%); Religious Affiliation- Christian 13/14 (93%), None 1/14 (7%); Married/Partner 2/14 (14%). Patient demographics including sex (p 0.6), religious beliefs (p 0.8), and marital status (p 0.6) did not show any correlation with the likelihood of ACP completion. Of the 31 residents who answered the survey, the most commonly listed barriers to ACP completion were the following: lack of time to conduct these discussions (94%), forgetting to conduct ACP discussions (48%), and lack of training (19%). All the residents believed that ACP discussion was beneficial to patients and medical providers. Conclusions: The rates of ACP planning in our clinic are much lower than the national average. African American and Hispanics, who make up the majority of our clinic population, traditionally have had low rates of ACP completion. This is an important issue that needs to be addressed. Advance care planning training should be also be strengthened during residency. [Table: see text]

scholarly journals GOALS OF CARE IN END-STAGE RENAL DISEASE: THE INFLUENCE OF AGE AND MULTIMORBIDITY

2019 ◽  
Vol 3 (Supplement_1) ◽  
pp. S123-S123
Author(s):  
Deborah P Waldrop ◽  
Patricia Denny ◽  
Sandra Lauer ◽  
Kathleen Grimm ◽  
Phyllis Murawski ◽  
...  
Keyword(s):  
Older Adults ◽  
Renal Disease ◽  
Advance Care Planning ◽  
End Stage Renal Disease ◽  
Symptom Burden ◽  
Care Planning ◽  
Goals Of Care ◽  
Advance Care ◽  
Stage Renal Disease ◽  
End Stage

Abstract The number of people with End Stage Renal Disease (ESRD) who need dialysis treatment has increased sharply among adults age 75+. Older adults on dialysis have lower rates of advance care planning and higher treatment intensity, hospitalization and intensive care than people other chronic illnesses. Comprehensive care of older adults with ESRD includes advance care planning that addresses goals of care and not just specific medical treatments. The purpose of this study was to explore the nature of symptom burden and advance care planning in dialysis patients. The study design was exploratory, descriptive and cross-sectional. Quantitative and qualitative data were collected during in-person chairside interviews with people having dialysis treatments. Categorical questions focused on demographics and advance directives. The Dialysis Symptom Inventory was used to measure symptom burden. Open-ended questions addressed the trajectory of illness and goals of care. Thirty-five interviews were conducted. Participants’ Mage=55.8 years (range 27-84); 51 % were >60. A distinctive pattern of difference by age emerged. Participants >60 demonstrated greater multimorbidity and lower symptom burden (MDSI=30.13; Range 11-63) compared with those <60 (MDSI=36.31; Range 3-78). Goals of care also varied with age. Older adults’ goals were: (1) Functional (e.g. to walk better, drive); and (2) Existential (e.g. maintaining, surviving, enjoying). Goals of participants <60 were: (1) Transplantation; and (2) Engagement (e.g. work, school, travel). The results suggest that the illness experience and goals are influenced by age and multimorbidity. Implications: ESRD-specific advance care planning conversations with a focus on goals of care are important.

scholarly journals Advance care planning for 600 Chinese patients with end-stage renal disease

2016 ◽  
Vol 19 ◽  
pp. 19-27 ◽  
Author(s):  
Sze-Kit Yuen ◽  
Hay Ping Suen ◽  
Oi-Ling Kwok ◽  
Sai-Ping Yong ◽  
Man-Wah Tse
Keyword(s):  
Renal Disease ◽  
Advance Care Planning ◽  
End Stage Renal Disease ◽  
Chinese Patients ◽  
Care Planning ◽  
Advance Care ◽  
Stage Renal Disease ◽  
End Stage

Matters of Life and Death: Why Do Older Patients Choose Conservative Management?

2019 ◽  
Vol 51 (1) ◽  
pp. 35-42
Author(s):  
Fahad Saeed ◽  
Hugh Adams ◽  
Ronald M. Epstein
Keyword(s):  
United States ◽  
Decision Making ◽  
Clinical Experience ◽  
Advance Care Planning ◽  
Conservative Management ◽  
Primary Care Physicians ◽  
Older Patients ◽  
The United States ◽  
Care Planning ◽  
Advance Care

Background: Although many older patients with end-stage renal disease and limited prognoses prefer conservative management (CM), it is not widely offered in the United States. Moreover, there is a dearth of US-based literature reporting clinical experience with shared decision making regarding CM of advanced chronic kidney disease (CKD). Methods: We describe the clinical experience of 13 patients who opted for CM at the University of Rochester Medical Center’s CKD clinic during 2016–2017. Main outcomes include: (1) reason for choosing CM, (2) completion of advance directives, (3) location of death, and (4) utilization of hospice service. Patients’ reasons for choosing CM were categorized into 4 broad categories based on a review of their electronic medical records. A retrospective chart review conducted by 2 reviewers determined the status of advance care planning, hospice referral, and place of death. Results: The mean age of these patients was 81.8 years (SD 7.3). Their reasons for choosing CM included: poor prognoses; a wish to maintain their quality of life; their desire for a dignified life closure; and the intention to protect family members from having to see them suffer, based on their own memory of having witnessed a relative on dialysis previously. A total of 8 patients died: all received hospice services, 6 died at home, one at a nursing home, and one at a hospital. Advance care planning was completed in 100% of the cases. Symptoms were managed in collaboration with primary care physicians. Conclusion: Patients’ decisions to choose CM were influenced by their values and previous experience with dialysis, in addition to comorbidities and limited prognoses. Promoting the choice of CM in the United States will require training of clinicians in primary palliative care competencies, including communication and decision-making skills, as well as basic symptom management proficiencies.

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