Format

Send to

Choose Destination
BMC Palliat Care. 2019 Jul 26;18(1):64. doi: 10.1186/s12904-019-0437-2.

Advance care planning with patients on hemodialysis: an implementation study.

Author information

1
University of Massachusetts Medical School-Baystate, 759 Chestnut St., Springfield, MA, 01199, USA. sgoff@umass.edu.
2
Present Address: School of Public Health and Health Sciences, University of Massachusetts-Amherst, Amherst, MA, 01002, USA. sgoff@umass.edu.
3
School of Medicine, University of New Mexico, Albuquerque, NM, 87131, USA.
4
University of Massachusetts Medical School-Baystate, 759 Chestnut St., Springfield, MA, 01199, USA.
5
Present Address: Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA.
6
Massachusetts General Hospital, 55 Fruit St., Boston, MA, 02114, USA.
7
Northeastern University, 360 Huntington Ave, Boston, MA, 02115, USA.

Abstract

BACKGROUND:

Patients with end-stage kidney disease (ESKD) on hemodialysis have limited life expectancy, yet their palliative care needs often go unmet. The aim of this study was to identify barriers and facilitators for implementation of "Shared Decision Making and Renal Supportive Care" (SDM-RSC), an intervention to improve advance care planning (ACP) for patients with ESKD on hemodialysis.

METHODS:

The Consolidated Framework for Implementation Research (CFIR) was the organizing framework for this study. CFIR is a theory-based implementation framework consisting of five domains (Intervention Characteristics, Inner Setting, Outer Setting, Characteristics of Individuals, and Process), each of which has associated constructs. Potential barriers and facilitators to implementation of the SDM-RSC intervention were identified through observation of study procedures, surveys of social workers nephrologists, study participants, and family members, and assessment of intervention fidelity.

RESULTS:

Twenty-nine nephrologists and 24 social workers, representing 18 outpatient dialysis units in Massachusetts (nā€‰=ā€‰10) and New Mexico (nā€‰=ā€‰8), were trained to conduct SDM-RSC intervention sessions. A total of 102 of 125 patient enrolled in the study received the intervention; 40 had family members present. Potential barriers and facilitators to implementation of the SDM-RSC intervention were identified in each of the five CFIR domains. Barriers included complexity of the intervention; challenges to meeting with patients on non-dialysis days; difficulties scheduling intervention sessions due to nephrologists' and social workers' caseloads; perceived need for local policy change regarding ACP; perceived need for additional ACP training for social workers and nephrologists; and lack of endorsement of the intervention by some staff members. Facilitators included: training for social workers, national dialysis chain leadership engagement and the institution of social worker/nephrologist clinic champions.

CONCLUSIONS:

ACP for patients on hemodialysis can have a positive impact on end-of-life outcomes for patients and their families but does not take place routinely. The barriers to effective implementation of interventions to improve ACP identified in this study might be addressed by: adapting the intervention for local contexts with input from clinicians, dialysis staff, patients and families; providing nephrologists and social workers additional training prior to delivering the intervention; and developing policy that routinizes ACP for hemodialysis patients.

TRIAL REGISTRATION:

Clinicaltrials.gov NCT02405312. Registered 04/01/2015.

KEYWORDS:

Advance care planning; End-of-life; Hemodialysis; Implementation; Intervention; Shared decision-making

Supplemental Content

Full text links

Icon for BioMed Central Icon for PubMed Central
Loading ...
Support Center