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Am J Kidney Dis. 2016 Jul;68(1):103-9. doi: 10.1053/j.ajkd.2015.11.024. Epub 2016 Jan 22.

Nephrologist-Facilitated Advance Care Planning for Hemodialysis Patients: A Quality Improvement Project.

Author information

1
Division of Nephrology, Department of Medicine, Tufts Medical Center, Boston, MA; Department of Medicine, Tufts University School of Medicine, Boston, MA.
2
Department of Medicine, Tufts University School of Medicine, Boston, MA; Division of Nephrology, Department of Medicine, St Elizabeth Medical Center, Boston, MA.
3
Department of Medicine, Tufts University School of Medicine, Boston, MA; Division of Nephrology, Department of Medicine, St Elizabeth Medical Center, Boston, MA. Electronic address: bertrand.jaber@steward.org.

Abstract

BACKGROUND:

The Renal Physicians Association's clinical practice guideline recommends that physicians address advance care planning with dialysis patients. However, data are lacking about how best to implement this recommendation.

STUDY DESIGN:

Quality improvement project.

SETTINGS & PARTICIPANTS:

Nephrologists caring for patients treated with maintenance hemodialysis at 2 dialysis facilities identified patients who might benefit most from advance care planning using the "surprise" question ("Would I be surprised if this patient died in the next year?").

QUALITY IMPROVEMENT PLAN:

Patients identified with a "no" response to the surprise question were invited to participate in nephrologist-facilitated advance care planning, including completion of a Medical Orders for Life-Sustaining Treatment (MOLST) form.

OUTCOMES:

Change in MOLST completion rate and identification of preferences for limits on life-sustaining treatment.

MEASUREMENTS:

Pre- and postintervention code status, MOLST completion rate, and vital status at 1 year.

RESULTS:

Nephrologists answered "no" to the surprise question for 50 of 201 (25%) hemodialysis patients. Of these, 41 (82%) patients had a full-code status and 9 (18%) had a do-not-resuscitate (DNR) status. Encounters lasted 15 to 60 minutes. Following the encounter, 21 (42%) patients expressed preference for a DNR status and 29 (58%) maintained full-code status (P=0.001). The MOLST completion rate increased from 10% to 90%. One-year survival for patients whose nephrologists answered "no" to the surprise question was 58% compared to 92% for those with a "yes" answer (P<0.001).

LIMITATIONS:

Sample size and possible nonrepresentative dialysis population.

CONCLUSIONS:

Nephrologist-facilitated advance care planning targeting hemodialysis patients with limited life expectancy led to significant changes in documented patient preferences for cardiopulmonary resuscitation and limits on life-sustaining treatment. These changes demonstrate the benefit of advance care planning with dialysis patients and likely reflect better understanding of end-of-life treatment options.

KEYWORDS:

Advance care planning; cardiopulmonary resuscitation; code status; do not resuscitate (DNR); end-of-life care; end-stage renal disease (ESRD); hemodialysis; life expectancy; medical orders for life-sustaining treatment (MOLST); physician orders for life-sustaining treatment (POLST); quality improvement; shared decision making

Comment in

PMID:
26806003
PMCID:
PMC4921274
DOI:
10.1053/j.ajkd.2015.11.024
[Indexed for MEDLINE]
Free PMC Article

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