Implementation and Effectiveness of a Learning Collaborative to Improve Palliative Care for Seriously Ill Hemodialysis Patients

Abstract

Background and objectivesLimited implementation of palliative care practices in hemodialysis may contribute to end-of-life care that is intensive and not patient centered. We determined whether a learning collaborative for hemodialysis center providers improved delivery of palliative care best practices.Design, setting, participants, & measurementsTen US hemodialysis centers participated in a pre-post study targeting seriously ill patients between April 2019 and September 2020. Three practices were prioritized: screening for serious illness, goals of care discussions, and use of a palliative dialysis care pathway. The collaborative educational bundle consisted of learning sessions, communication skills training, and implementation support. The primary outcome was change in the probability of complete advance care planning documentation among seriously ill patients. Health care utilization was a secondary outcome, and implementation outcomes of acceptability, adoption, feasibility, and penetration were assessed using mixed methods.ResultsOne center dropped out due to the coronavirus disease 2019 pandemic. Among the remaining nine centers, 20% (273 of 1395) of patients were identified as seriously ill preimplementation, and 16% (203 of 1254) were identified as seriously ill postimplementation. From the preimplementation to postimplementation period, the adjusted probability of complete advance care planning documentation among seriously ill patients increased by 34.5 percentage points (95% confidence interval, 4.4 to 68.5). There was no difference in mortality or in utilization of palliative hemodialysis, hospice referral, or hemodialysis discontinuation. Screening for serious illness was widely adopted, and goals of care discussions were adopted with incomplete integration. There was limited adoption of a palliative dialysis care pathway.ConclusionsA learning collaborative for hemodialysis centers spanning the coronavirus disease 2019 pandemic was associated with adoption of serious illness screening and goals of care discussions as well as improved documentation of advance care planning for seriously ill patients.Clinical Trial registry name and registration number:Pathways Project: Kidney Supportive Care, NCT04125537

Palliative Care for Hemodialysis Patients?

“…In the modern era, however, such programs as VitalTalk and NephroTalk have adapted generic communication skills workshops for nephrology clinicians (10). Kurella Tamura et al (3) are to be commended for including such training in the learning collaborative package provided to the clinicians. The difficulty is the generalizability of this learning collaborative package: the capacity of nephrologists to embark on such intense training in addition to their usual schedule.…”

“…Are dialysis units, or indeed nephrologists, really ready to embrace such support? Kurella Tamura et al (3) in this issue of CJASN attempt to assess the effect of a learning collaborative program on the implementation of several of these domains. The study commences by reference to best practices in palliative care for patients on dialysis judged to be seriously ill (4), including screening for serious illness, a goals of care discussion, and use of a palliative care pathway.…”

“…Logically, in a dialysis setting, it should also include a statement about the circumstances in which dialysis is withdrawn. It is notable that, in the study by Kurella Tamura et al (3), no center appears to have adopted a protocol of dialysis withdrawal. This appears to be a lost opportunity or else reflects a hesitancy to discuss dialysis withdrawal.…”

“…The study by Kurella Tamura et al (3) illustrates both the opportunities and the challenges of ACPs in nephrology and points to the challenges of adopting palliative care, in its wholesome sense, into a dialysis unit. Those challenges are not insuperable but require concentration on each element of palliative care, including the ACP process, led by nephrologists who are prepared to realistically inform and guide their patients and families in their future planning and offer integrated palliative care within the dialysis unit.…”

“…The Renal Physicians Association of America, in their seminal document Shared Decision-Making in the Appropriate Initiation of and Withdrawal from Dialysis , recommended that ACPs should be completed for all patients on dialysis (6). In the study by Kurella Tamura et al (3), the authors concentrated on the surprise question—patients with an estimated prognosis of 6–12 months. The surprise question is a guide to prognosis; it is not perfect.…”