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Am J Kidney Dis. 2015 Nov;66(5):813-22. doi: 10.1053/j.ajkd.2015.05.018. Epub 2015 Jun 30.

Advance care planning and end-of-life decision making in dialysis: a randomized controlled trial targeting patients and their surrogates.

Author information

1
School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, NC. Electronic address: songm@email.unc.edu.
2
School of Nursing, University of Wisconsin-Madison, Madison, WI.
3
School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC.
4
School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC.
5
University of North Carolina Kidney Center, Chapel Hill, NC.
6
School of Nursing, Johns Hopkins University, Baltimore, MD.
7
School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, NC.

Abstract

BACKGROUND:

Few trials have examined long-term outcomes of advance care planning (ACP) interventions. We examined the efficacy of an ACP intervention on preparation for end-of-life decision making for dialysis patients and surrogates and for surrogates' bereavement outcomes.

STUDY DESIGN:

A randomized trial compared an ACP intervention (Sharing Patient's Illness Representations to Increase Trust [SPIRIT]) to usual care alone, with blinded outcome assessments.

SETTING & PARTICIPANTS:

420 participants (210 dyads of prevalent dialysis patients and their surrogates) from 20 dialysis centers.

INTERVENTION:

Every dyad received usual care. Those randomly assigned to SPIRIT had an in-depth ACP discussion at the center and a follow-up session at home 2 weeks later.

OUTCOMES & MEASUREMENTS:

PRIMARY OUTCOMES:

preparation for end-of-life decision making, assessed for 12 months, included dyad congruence on goals of care at end of life, patient decisional conflict, surrogate decision-making confidence, and a composite of congruence and surrogate decision-making confidence.

SECONDARY OUTCOMES:

bereavement outcomes, assessed for 6 months, included anxiety, depression, and posttraumatic distress symptoms completed by surrogates after patient death.

RESULTS:

PRIMARY OUTCOMES:

adjusting for time and baseline values, dyad congruence (OR, 1.89; 95% CI, 1.1-3.3), surrogate decision-making confidence (β=0.13; 95% CI, 0.01-0.24), and the composite (OR, 1.82; 95% CI, 1.0-3.2) were better in SPIRIT than controls, but patient decisional conflict did not differ between groups (β=-0.01; 95% CI, -0.12 to 0.10).

SECONDARY OUTCOMES:

45 patients died during the study. Surrogates in SPIRIT had less anxiety (β=-1.13; 95% CI, -2.23 to -0.03), depression (β=-2.54; 95% CI, -4.34 to -0.74), and posttraumatic distress (β=-5.75; 95% CI, -10.9 to -0.64) than controls.

LIMITATIONS:

Study was conducted in a single US region.

CONCLUSIONS:

SPIRIT was associated with improvements in dyad preparation for end-of-life decision making and surrogate bereavement outcomes.

KEYWORDS:

Advance care planning (ACP); advanced kidney disease; bereavement; death; dyad congruence; emotional distress; end-of-life decision making; end-stage renal disease (ESRD); hemodialysis; life-sustaining treatment; medical decision; patient education intervention; patient-surrogate dyad; randomized controlled trial (RCT); surrogate decision maker; treatment options

PMID:
26141307
PMCID:
PMC5972830
DOI:
10.1053/j.ajkd.2015.05.018
[Indexed for MEDLINE]
Free PMC Article

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