Program Profile

Nephrology–Palliative Care Collaboration to Promote Outpatient Hemodialysis Goals of Care Conversations

Fed Pract. 2023 October;40(10):349 | doi:10.12788/fp.0422

Author(s):

Alexi Vahlkamp, MA

Julia Schneider, MD

Talar Markossian, PhD

Salva Balbale, PhD

Cara Ray, PhD

Kevin Stroupe, PhD

Seema Limaye, MD

Background: Goals of care conversations and corresponding life-sustaining treatment (LST) progress notes were completed for only one-fourth of patients on outpatient dialysis despite hospital-wide training with nephrologists at the Edward Hines, Jr. Veterans Affairs Hospital. The purpose of this quality improvement project was to increase completion of LST progress notes and corresponding orders among patients on dialysis through an interdisciplinary nephrology–palliative care collaboration.

Observations: The nephrology and palliative care departments began an interdisciplinary collaboration for nephrology to consult palliative care to initiate goals of care conversations and complete LST progress notes with patients on dialysis. A coordinated workflow process was created that included multidisciplinary efforts for patient selection, patient education, and introduction and completion of goals of care conversations for patients on dialysis. Completion rates for LST notes increased from 27% to 81% following the 13-month intervention, with 69 of 85 patients having a documented LST progress note.

Conclusions: A collaboration between nephrology and palliative care increased high-quality LST progress note completion. The next steps include expanding these collaborations at other dialysis units and evaluating the impact on patient outcomes.

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References

2. Weisbord SD, Carmody SS, Bruns FJ, et al. Symptom burden, quality of life, advance care planning and the potential value of palliative care in severely ill haemodialysis patients. Nephrol Dial Transplant. 2003;18(7):1345-1352. doi:10.1093/ndt/gfg105

3. Wachterman MW, Marcantonio ER, Davis RB, et al. Relationship between the prognostic expectations of seriously ill patients undergoing hemodialysis and their nephrologists. JAMA Intern Med. 2013;173(13):1206-1214. doi:10.1001/jamainternmed.2013.6036

4. Davison SN. End-of-life care preferences and needs: perceptions of patients with chronic kidney disease. Clin J Am Soc Nephrol. 2010;5(2):195-204. doi:10.2215/CJN.05960809

5. Williams AW, Dwyer AC, Eddy AA, et al; American Society of Nephrology Quality, and Patient Safety Task Force. Critical and honest conversations: the evidence behind the “Choosing Wisely” campaign recommendations by the American Society of Nephrology. Clin J Am Soc Nephrol. 2012;7(10):1664-1672. doi:10.2215/CJN.04970512

6. Renal Physicians Association. Shared Decision-Making in the Appropriate Initiation of and Withdrawal from Dialysis. 2nd ed. Renal Physicians Association; 2010.

7. US Department of Veterans Affairs, National Center for Ethics in Health Care. Goals of care conversations training for nurses, social workers, psychologists, and chaplains. Updated October 9, 2018. Accessed August 31, 2023. https://www.ethics.va.gov/goalsofcaretraining/team.asp

8. Goff SL, Unruh ML, Klingensmith J, et al. Advance care planning with patients on hemodialysis: an implementation study. BMC Palliat Care. 2019;18(1):64. Published 2019 Jul 26. doi:10.1186/s12904-019-0437-2

9. O’Hare AM, Szarka J, McFarland LV, et al. Provider perspectives on advance care planning for patients with kidney disease: whose job is it anyway? Clin J Am Soc Nephrol. 2016;11(5):855-866. doi:10.2215/CJN.11351015

10. Koncicki HM, Schell JO. Communication skills and decision making for elderly patients with advanced kidney disease: a guide for nephrologists. Am J Kidney Dis. 2016;67(4):688-695. doi:10.1053/j.ajkd.2015.09.032

11. Holley JL, Davison SN. Advance care planning for patients with advanced CKD: a need to move forward. Clin J Am Soc Nephrol. 2015;10(3):344-346. doi:10.2215/CJN.00290115

12. Davison SN. Facilitating advance care planning for patients with end-stage renal disease: the patient perspective. Clin J Am Soc Nephrol. 2006;1(5):1023-1028. doi:10.2215/CJN.01050306

13. Murray AM, Arko C, Chen SC, Gilbertson DT, Moss AH. Use of hospice in the United States dialysis population. Clin J Am Soc Nephrol. 2006;1(6):1248-1255. doi:10.2215/CJN.00970306

14. Williams ME, Sandeep J, Catic A. Aging and ESRD demographics: consequences for the practice of dialysis. Semin Dial. 2012;25(6):617-622. doi:10.1111/sdi.12029

15. US Dept of Veterans Affairs. FY 2020 annual report. Palliative and hospice care.

16. Chandna SM, Da Silva-Gane M, Marshall C, Warwicker P, Greenwood RN, Farrington K. Survival of elderly patients with stage 5 CKD: comparison of conservative management and renal replacement therapy. Nephrol Dial Transplant. 2011;26(5):1608-1614. doi:10.1093/ndt/gfq630

17. Fadem SZ, Fadem J. HD mortality predictor. Accessed August 31, 2023. http://touchcalc.com/calculators/sq

18. National Center for Ethics in Health Care. Setting health care goals: a guide for people with hearth problems. Updated June 2016. Accessed August 31, 2023. https://www.ethics.va.gov/docs/GoCC/lst_booklet_for_patients_setting_health_care_goals_final.pdf

Estimates of chronic kidney disease (CKD) among veterans range between 34% and 47% higher than in the general population.¹ As patients progress to end-stage kidney disease and begin chronic dialysis, they often experience further functional and cognitive decline and a high symptom burden, leading to poor quality of life.² Clinicians should initiate goals of care conversations (GOCCs) to support high-risk patients on dialysis to ensure that the interventions they receive align with their goals and preferences, since many patients on dialysis prefer measures focused on pain relief and discomfort.^3,4 While proactive GOCCs are supported among nephrology associations, few such conversations take place.^5,6 In one study, more than half of patients on dialysis stated they had not discussed end-of-life preferences in the past 12 months.⁴ As a result, patients may not consider the larger implications of receiving dialysis indefinitely as a life-sustaining treatment (LST).

In May 2018, the US Department of Veterans Affairs (VA) National Center for Ethics in Health Care rolled out the Life-Sustaining Treatment Decisions Initiative to proactively engage patients with serious illnesses, such as those with end-stage kidney disease, in GOCCs to clarify their preferences for LSTs.⁷ After comprehensive training, a preliminary audit at the Edward Hines, Jr. VA Hospital (EHJVAH) in Hines, Illinois, revealed that only 27% of patients on dialysis had LST preferences documented in a standardized LST note.

Nephrologists cite multiple barriers to proactively addressing goals of care with patients with advanced CKD, including clinician discomfort, perceived lack of time, infrastructure, and training.^8,9 Similarly, the absence of a multidisciplinary advance care planning approach—specifically bringing together palliative care (PC) clinicians with nephrologists—has been highlighted but not as well studied.^10,11

In this quality improvement (QI) project, we aimed to establish a workflow to enhance collaboration between nephrology and PC and to increase the percentage of VA patients on outpatient hemodialysis who engaged in GOCCs, as documented by completion of an LST progress note in the VA’s electronic health record (EHR). We developed a collaboration among PC, nephrology, and social work to improve the rates of documented GOCCs and LST patients on dialysis.

References

1. Patel N, Golzy M, Nainani N, et al. Prevalence of various comorbidities among veterans with chronic kidney disease and its comparison with other datasets. Ren Fail. 2016;38(2):204-208. doi:10.3109/0886022X.2015.1117924

2. Weisbord SD, Carmody SS, Bruns FJ, et al. Symptom burden, quality of life, advance care planning and the potential value of palliative care in severely ill haemodialysis patients. Nephrol Dial Transplant. 2003;18(7):1345-1352. doi:10.1093/ndt/gfg105

3. Wachterman MW, Marcantonio ER, Davis RB, et al. Relationship between the prognostic expectations of seriously ill patients undergoing hemodialysis and their nephrologists. JAMA Intern Med. 2013;173(13):1206-1214. doi:10.1001/jamainternmed.2013.6036

4. Davison SN. End-of-life care preferences and needs: perceptions of patients with chronic kidney disease. Clin J Am Soc Nephrol. 2010;5(2):195-204. doi:10.2215/CJN.05960809

5. Williams AW, Dwyer AC, Eddy AA, et al; American Society of Nephrology Quality, and Patient Safety Task Force. Critical and honest conversations: the evidence behind the “Choosing Wisely” campaign recommendations by the American Society of Nephrology. Clin J Am Soc Nephrol. 2012;7(10):1664-1672. doi:10.2215/CJN.04970512

6. Renal Physicians Association. Shared Decision-Making in the Appropriate Initiation of and Withdrawal from Dialysis. 2nd ed. Renal Physicians Association; 2010.

7. US Department of Veterans Affairs, National Center for Ethics in Health Care. Goals of care conversations training for nurses, social workers, psychologists, and chaplains. Updated October 9, 2018. Accessed August 31, 2023. https://www.ethics.va.gov/goalsofcaretraining/team.asp

8. Goff SL, Unruh ML, Klingensmith J, et al. Advance care planning with patients on hemodialysis: an implementation study. BMC Palliat Care. 2019;18(1):64. Published 2019 Jul 26. doi:10.1186/s12904-019-0437-2

9. O’Hare AM, Szarka J, McFarland LV, et al. Provider perspectives on advance care planning for patients with kidney disease: whose job is it anyway? Clin J Am Soc Nephrol. 2016;11(5):855-866. doi:10.2215/CJN.11351015

10. Koncicki HM, Schell JO. Communication skills and decision making for elderly patients with advanced kidney disease: a guide for nephrologists. Am J Kidney Dis. 2016;67(4):688-695. doi:10.1053/j.ajkd.2015.09.032

11. Holley JL, Davison SN. Advance care planning for patients with advanced CKD: a need to move forward. Clin J Am Soc Nephrol. 2015;10(3):344-346. doi:10.2215/CJN.00290115

12. Davison SN. Facilitating advance care planning for patients with end-stage renal disease: the patient perspective. Clin J Am Soc Nephrol. 2006;1(5):1023-1028. doi:10.2215/CJN.01050306

13. Murray AM, Arko C, Chen SC, Gilbertson DT, Moss AH. Use of hospice in the United States dialysis population. Clin J Am Soc Nephrol. 2006;1(6):1248-1255. doi:10.2215/CJN.00970306

14. Williams ME, Sandeep J, Catic A. Aging and ESRD demographics: consequences for the practice of dialysis. Semin Dial. 2012;25(6):617-622. doi:10.1111/sdi.12029

15. US Dept of Veterans Affairs. FY 2020 annual report. Palliative and hospice care.

16. Chandna SM, Da Silva-Gane M, Marshall C, Warwicker P, Greenwood RN, Farrington K. Survival of elderly patients with stage 5 CKD: comparison of conservative management and renal replacement therapy. Nephrol Dial Transplant. 2011;26(5):1608-1614. doi:10.1093/ndt/gfq630

17. Fadem SZ, Fadem J. HD mortality predictor. Accessed August 31, 2023. http://touchcalc.com/calculators/sq

18. National Center for Ethics in Health Care. Setting health care goals: a guide for people with hearth problems. Updated June 2016. Accessed August 31, 2023. https://www.ethics.va.gov/docs/GoCC/lst_booklet_for_patients_setting_health_care_goals_final.pdf

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Nephrology–Palliative Care Collaboration to Promote Outpatient Hemodialysis Goals of Care Conversations

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