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

Abstract

Background The Renal Physicians Association’s clinical practice guideline recommends that physicians address advance care planning with dialysis patients. Data are lacking, however, about how best to implement this recommendation. Study Design Quality improvement project in two Tufts-affiliated dialysis facilities in Boston, Massachusetts. Settings and Participants Nephrologists caring for patients treated with maintenance hemodialysis at two 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 the use 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 post-intervention cardiopulmonary resuscitation status, MOLST completion rate, and vital status at one year were measured. Results Nephrologists answered ‘no’ to the surprise question for 50 of 201 hemodialysis patients (25%). Of these, 41 (82%) patients had a ‘full-code’ status and 9 (18%) had a ‘do not resuscitate’ (DNR) status. Encounters lasted 15–60 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 with 92% for those with a ‘yes’ answer (p < 0.001). Limitations Sample size and possible non-representative 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.

The “surprise question” for predicting death in seriously ill patients: a systematic review and meta-analysis

“…14,19 In 3 studies, the SQ was used only to predict 7-and/or 30-day mortality. 29,37,38 Sixteen remaining studies of SQ to predict death met inclusion criteria 1,[20][21][22][23][24][25][26][27][28][30][31][32][33][34][35] (Table 1) and were included in the meta-analysis. One study provided data for a derivation cohort in the manuscript.…”

“…34 The SQ was answered by physicians in 13 studies (including oncologists, 26,33,35 nephrologists, 20,22,[30][31][32] respirologists, 23 intensivists, 24 and general practitioners 21,25,34 ), specialist nurses in 1 study, 1 either a physician or a nurse in 1 study 28 and a multidisciplinary team of 2 physicians and a nurse in another study. 27 In each case, the assessors were familiar with the patient.…”

“…1,20,21,[23][24][25][26]31,33,35 One study asked the SQ to a multidisciplinary team, which arrived at an answer by consensus. 27 In 1 study of patients receiving hemodialysis, every physician and nurse working with that patient was asked the SQ independently; to be consistent, we considered that the patient was SQ+ if either of the 2 physicians attending in their unit responded "no" to the SQ.…”

“…We contacted 6 authors to clarify or obtain additional data. 21,26,30,31,33,35 Using data from all 17 cohorts (Table 4), the meta-analytic estimates were as follows: of sensitivity 67.0% (95% confidence interval [CI] 55.7%-76.7%), specificity 80.2% (73.3%-85.6%), LR+ 3.4 (95% CI 2.8-4.1), LR-0.41 (95% CI 0.32-0.54), PPV 37.1% (95% CI 30.2%-44.6%) and NPV 93.1% (95% CI 91.0%-94.8%). The sROC model showed moderate discriminatory ability (Figure 2), with an AUC of 0.81 (95% CI 0.78-0.86).…”

Dialysis Therapy and Conservative Management of Advanced Chronic Kidney Disease in the Elderly: A Systematic Review

“…Shared decision-making using a patient-centered and multidisciplinary approach where patients are fully informed about their prognosis and risks and benefits of treatment options, and where they are assured that their values and preferences play a prominent role, has been suggested by a recent practice guideline for dialysis initiation [31] . Advance care planning discussions with patients who have limited life expectancy [32] and early designation of a health care agent or legal guardian before cognitive impairment complicates patient decision-making capabilities should be promoted [33] .…”