Palliative Dialysis

2020 ◽  
pp. 220-226
Author(s):  
Vanessa Grubbs
Keyword(s):  
Decision Making ◽  
Heart Disease ◽  
Survival Benefit ◽  
Older Patients ◽  
Poor Prognosis ◽  
Care Plan ◽  
Patient Centered ◽  
Life Saving ◽  
Standard Quality ◽  
End Stage

Dialysis is typically thought of as a life-saving treatment for patients with end-stage kidney disease (ESKD), but for a subset of older patients with dementia or ischemic heart disease or other advanced comorbidities it may not confer a survival benefit, stop the ESKD trajectory, and be life-extending despite achieving standard quality metrics. Providers should consider palliative dialysis for patients with ESKD who have a life expectancy of less than one 1 year, symptoms that might be ameliorated by dialysis, and values such that they would consider a trial of dialysis. Offering palliative dialysis should be considered part of a patient-centered approach for some patients with ESKD with a poor prognosis even with dialysis. In this broadened view of choices for patients with ESKD, decision-making need not only include forgoing or withdrawing dialysis as options. Dialysis is a care plan that strives to achieve hopes while minimizing fears. This balance of the positives and negatives of dialysis can be thought of as palliative dialysis.

Challenges faced by patients, relatives and clinicians in end-stage dementia decision-making: a qualitative study of swallowing problems

2020 ◽  
pp. medethics-2020-106222
Author(s):  
Joseph Dimech ◽  
Emmanuel Agius ◽  
Julian C Hughes ◽  
Paul Bartolo
Keyword(s):  
Decision Making ◽  
End Of Life ◽  
Ethical Issues ◽  
Tube Feeding ◽  
Care Plan ◽  
Term Care ◽  
Swallowing Problems ◽  
Swallowing Difficulties ◽  
Life Threatening ◽  
End Stage

BackgroundDecision-making in end-stage dementia (ESD) is a complex process involving medical, social, legal and ethical issues. In ESD, the person suffers from severe cognitive problems leading to a loss of capacity to decide matters regarding health and end-of-life issues. The decisional responsibility is usually passed to clinicians and relatives who can face significant difficulty in making moral decisions, particularly in the presence of life-threatening swallowing problems.AimThis study aimed to understand the decision-making processes of clinical teams and relatives in addressing life-threatening swallowing difficulties in ESD in long-term care in Malta.MethodThe study followed a qualitative approach where six case studies, involving six different teams and relatives of six different patients, were interviewed retrospectively to understand their decision-making in connection with the management of swallowing difficulties in ESD. Data were collected through semistructured interviews with each stakeholder. All data were transcribed and subjected to thematic analysis.ResultsFour themes were identified: the vulnerability of patients in dementia decision-making; the difficult role of relatives in decision-making; the decisional conflict between aggressive care through tube feeding versus oral comfort feeding; a consensus-building decision-making process as ideal to facilitate agreement and respect for patient’s dignity.ConclusionDecision-making to manage swallowing difficulties in ESD is a challenging process, which involves an interpretation of personal values, beliefs, patient preferences, care needs and clinical practice. Better communication between clinicians and relatives in dementia helps promote agreement between stakeholders leading to a care plan that respects the dignity of patients at their end of life.

scholarly journals Development of a risk stratification algorithm to improve patient-centered care and decision making for incident elderly patients with end-stage renal disease

2015 ◽  
Vol 88 (5) ◽  
pp. 1178-1186 ◽  
Author(s):  
Cécile G. Couchoud ◽  
Jean-Baptiste R. Beuscart ◽  
Jean-Claude Aldigier ◽  
Philippe J. Brunet ◽  
Olivier P. Moranne
Keyword(s):  
Decision Making ◽  
Risk Stratification ◽  
Elderly Patients ◽  
Renal Disease ◽  
End Stage Renal Disease ◽  
Patient Centered ◽  
Centered Care ◽  
Stage Renal Disease ◽  
End Stage ◽  
Improve Patient

scholarly journals Preoperative assessment of patients with end stage renal failure

2011 ◽  
Vol 58 (2) ◽  
pp. 131-136 ◽  
Author(s):  
Nebojsa Ladjevic ◽  
Nevena Kalezic ◽  
Ivana Likic-Ladjevic ◽  
Aleksandar Vuksanovic ◽  
Otas Durutovic ◽  
...  
Keyword(s):  
Renal Failure ◽  
Heart Disease ◽  
Older Patients ◽  
Fatal Outcome ◽  
Significant Risk ◽  
Preoperative Assessment ◽  
Chronically Ill ◽  
End Stage Renal Failure ◽  
Anesthetic Agents ◽  
End Stage

Patients with end stage renal failure (ESRF) present a number of challenges to the anesthesiologist. They may be chronically ill and debilitated and have the potential for multisystem organ dysfunction. Patients with primary renal disease are likely younger and have good cardiopulmonary reserve. Older patients with renal failure secondary to diabetes mellitus or hypertension may suffer the ravages of diffuse atherosclerosis and heart disease. To safely manage these patients we need to understand the benefits and limitations of dialysis, problems related with primary disease, pathophysiological effects of ESRF, and the altered pharmacology of commonly used anesthetic agents and perioperative medications in ESRF. Problems encountered by anesthesiologist in ESRF patients include hypertension, ischemic heart disease, congestive heart failure, anemia, metabolic acidosis, hyperkaliemia, hyponatremia and circulatory collapse. All surgical procedure in patients with ESRF carries significant risk of peri- and postoperative complications (mostly cardiovascular) and even fatal outcome.

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 Consumer health informatics approach for personalized cancer screening decisions using utility functions

2020 ◽  
Vol 26 (4) ◽  
pp. 2877-2891
Author(s):  
John Maleyeff ◽  
Danrong Chen
Keyword(s):  
Decision Making ◽  
Cancer Screening ◽  
Health Informatics ◽  
Utility Functions ◽  
Consumer Health Informatics ◽  
Consumer Health ◽  
Patient Centered ◽  
Life Saving ◽  
Central Composite Experimental Design ◽  
Personalized Cancer

A consumer health informatics approach is used to investigate the development of a patient-centered decision support system (DSS) with individualized utility functions. It supports medical decisions that have uncertain benefits and potential harms. Its use for accepting or declining cancer screening is illustrated. The system’s underlying optimization model incorporates two user-specific utility functions—one that quantifies life-saving benefits and one that quantifies harms, such as unnecessary follow-up tests, surgeries, or treatments. The system requires sound decision making. Therefore, the decision making process was studied using a decision aid in the form of a color-coded matrix with the potential outcomes randomly placed in proportion to their likelihoods. Data were collected from 48 study participants, based on a central composite experimental design. The results show that the DSS can be effective, but health consumers may not be rational decision makers.

Decision making on clinical care choices including end-of-life decision making for older adults in an acute care setting

2020 ◽  
Vol 70 (suppl 1) ◽  
pp. bjgp20X711725
Author(s):  
Sinead O’Reilly
Keyword(s):  
Decision Making ◽  
Older People ◽  
Medical Care ◽  
End Of Life ◽  
Older Patients ◽  
Care Setting ◽  
Clinical Care ◽  
Care Plan ◽  
Do Not Resuscitate ◽  
Health And Social Care

BackgroundThe Scottish Government’s vision for older people is that ‘Older people are valued as an asset; their voices are heard and they are supported to enjoy full and positive lives.’ In the health and social care setting in Scotland it is increasingly recognised that there is a need for careful planning of care for older patients with complex comorbidities, and that this should involve the patient where possible via a process of shared decision making (SDM).AimTo establish what future planning for healthcare decision making and end-of-life care was undertaken in the care of the older patients in a secondary care facility, and how much they participate in this process.MethodAn audit was conducted across four wards in the care of the older patient setting in a hospital for older patients in Scotland. Over a 2-week period, all patients’ charts (n = 82) were reviewed, and evidence was examined on whether the following documents were in place: a do not resuscitate order; an escalation of medical care plan; and an assessment of capacity/incapacity.ResultsThe majority of patients (55%) had a resuscitation plan in place. An Incapacity Statement was also in place for the majority of patients who required it (90%). The escalation of medical care plan was only completed for a minority of patients, mainly those on the palliative care ward.ConclusionPlans for decision making around resuscitation were reasonably well developed. However, planning for other, more complex, future medical care needs was less well defined or explored with older patients.

Palliative Care in End-Stage Renal Disease

2018 ◽  
Author(s):  
Linh My Thi Nguyen
Keyword(s):  
Decision Making ◽  
Renal Disease ◽  
End Stage Renal Disease ◽  
Symptom Management ◽  
Poor Prognosis ◽  
Interdisciplinary Team ◽  
Skin Lesions ◽  
Key Issues ◽  
Stage Renal Disease ◽  
End Stage

Patients with end-stage renal disease (ESRD) often experience a multitude of physical and psychosocial symptoms. The life expectancy of patients on dialysis is approximately 20% of that of age-matched individuals without renal disease. Of note, uremic calciphylaxis (or calcific uremic arteriopathy) can cause painful skin lesions and portends a poor prognosis. Frequent assessments, early intervention, and involvement of the interdisciplinary team are key to providing care for these patients. Decision-making for the initiation and withdrawal of dialysis is a complicated process. The prognosis after withdrawal of dialysis is usually short, and symptoms associated with uremia such as seizures and nausea should be treated promptly. This chapter discusses the key issues related to ESRD, including symptom management and end-of-life discussion.

Shared Decision-Making in the Context of Uncertain Care Goals and Outcomes: Dissecting a Penetrating Abdominal Trauma Case Complicated by Enterocutaneous Fistulae

2020 ◽  
Vol 86 (11) ◽  
pp. 1456-1461
Author(s):  
Buddy Marterre ◽  
Jaewook Shin ◽  
William T. Hillman Terzian
Keyword(s):  
Decision Making ◽  
Shared Decision Making ◽  
Treatment Options ◽  
Unintended Consequences ◽  
Care Plan ◽  
Morbidly Obese ◽  
Shared Decision ◽  
Patient Centered ◽  
Trauma Case ◽  
Experience Education

Surgeons care deeply about their patients, their patient’s surgical outcomes, and their fund of knowledge as it relates to disease, treatment options, and risk is remarkable. Unfortunately, surgical patients’ values, hopes, fears, and unacceptable levels of suffering are rarely elicited and addressed while constructing surgical treatment plans, even when the stakes are high. How can surgeons bring all their experience, education, and expertise to bear in a patient-centered manner amidst uncertainty? Surgeons typically emulate mentors who either employed a solely informative, facilitative, or directive/paternalistic approach to decision-making. These 3 styles fail to simultaneously address: (1) what matters most to patients and (2) the surgeon’s expertise. Since communication in each of these 3 approaches is unidirectional, and the decisional power locus is imbalanced, they are unshared, nonpartnering, and—perhaps surprisingly—not patient-centered. Patient-centered, collaborative shared decision-making (SDM) approaches align with palliative care principles and are rarely employed, taught, or modeled. Furthermore, nonpartnering approaches to surgical decision-making are often laden with unintended consequences, such as patient and family suffering and the suffering of surgeons. We present the high-risk case of an abdominal gunshot wound in a morbidly obese man, which was complicated by 3 enterocutaneous fistulae and a loss of abdominal wall integrity, where ongoing empathic, partnering SDM dialogue is enabling a patient-centered and value‐concordant care plan. The authors invite you to virtually journey with us as this case unfolds, as the impending surgical decisions are substantial and weighty. Uncertainty and risks appear at every turn—providing additional challenges to overcome.

The Role of Shared Decision-Making in Audiologic Rehabilitation

2014 ◽  
Vol 21 (1) ◽  
pp. 15-23 ◽  
Author(s):  
Helen Pryce ◽  
Amanda Hall
Keyword(s):  
Decision Making ◽  
Shared Decision Making ◽  
Behavior Changes ◽  
Shared Decision ◽  
Patient Centered ◽  
Treatment Information ◽  
Centered Care ◽  
Potential Risks ◽  
Audiologic Rehabilitation

Shared decision-making (SDM), a component of patient-centered care, is the process in which the clinician and patient both participate in decision-making about treatment; information is shared between the parties and both agree with the decision. Shared decision-making is appropriate for health care conditions in which there is more than one evidence-based treatment or management option that have different benefits and risks. The patient's involvement ensures that the decisions regarding treatment are sensitive to the patient's values and preferences. Audiologic rehabilitation requires substantial behavior changes on the part of patients and includes benefits to their communication as well as compromises and potential risks. This article identifies the importance of shared decision-making in audiologic rehabilitation and the changes required to implement it effectively.

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