Osama W Amro1, Malar Ramasamy1, James A Strom2, Daniel E Weiner1, Bertrand L Jaber3. 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.
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
Authors: Sara N Davison; Adeera Levin; Alvin H Moss; Vivekanand Jha; Edwina A Brown; Frank Brennan; Fliss E M Murtagh; Saraladevi Naicker; Michael J Germain; Donal J O'Donoghue; Rachael L Morton; Gregorio T Obrador Journal: Kidney Int Date: 2015-04-29 Impact factor: 10.612
Authors: Tim Luckett; Marcus Sellars; Jennifer Tieman; Carol A Pollock; William Silvester; Phyllis N Butow; Karen M Detering; Frank Brennan; Josephine M Clayton Journal: Am J Kidney Dis Date: 2014-01-14 Impact factor: 8.860
Authors: Celine Foote; Rachael L Morton; Meg Jardine; Martin Gallagher; Mark Brown; Kirsten Howard; Alan Cass Journal: Nephrol Dial Transplant Date: 2014-07-23 Impact factor: 5.992
Authors: Vanessa Grubbs; Alvin H Moss; Lewis M Cohen; Michael J Fischer; Michael J Germain; S Vanita Jassal; Jeffrey Perl; Daniel E Weiner; Rajnish Mehrotra Journal: Clin J Am Soc Nephrol Date: 2014-08-07 Impact factor: 8.237
Authors: Andrei D Javier; Rocio Figueroa; Edward D Siew; Huzaifah Salat; Jennifer Morse; Thomas G Stewart; Rakesh Malhotra; Manisha Jhamb; Jane O Schell; Cesar Y Cardona; Cathy A Maxwell; T Alp Ikizler; Khaled Abdel-Kader Journal: Am J Kidney Dis Date: 2017-02-15 Impact factor: 8.860
Authors: Huzaifah Salat; Andrei Javier; Edward D Siew; Rocio Figueroa; Loren Lipworth; Edmond Kabagambe; Aihua Bian; Thomas G Stewart; Maie H El-Sourady; Mohana Karlekar; Cesar Y Cardona; T Alp Ikizler; Khaled Abdel-Kader Journal: Clin J Am Soc Nephrol Date: 2017-09-18 Impact factor: 8.237
Authors: Manjula Kurella Tamura; Maria E Montez-Rath; Yoshio N Hall; Ronit Katz; Ann M O'Hare Journal: Clin J Am Soc Nephrol Date: 2017-01-05 Impact factor: 8.237
Authors: Manjula Kurella Tamura; Laura Holdsworth; Margaret Stedman; Annette Aldous; Steven M Asch; Jialin Han; Glenda Harbert; Karl A Lorenz; Elizabeth Malcolm; Amanda Nicklas; Alvin H Moss; Dale E Lupu Journal: Clin J Am Soc Nephrol Date: 2022-09-14 Impact factor: 10.614