ASN's Mission

To create a world without kidney diseases, the ASN Alliance for Kidney Health elevates care by educating and informing, driving breakthroughs and innovation, and advocating for policies that create transformative changes in kidney medicine throughout the world.

learn more

Contact ASN

1401 H St, NW, Ste 900, Washington, DC 20005


The Latest on Twitter

Kidney Week

Abstract: FR-PO907

Advanced Care Planning (ACP) among CKD and ESRD Patients: Kaiser Permanente Northern California (KPNC) Experience

Session Information

Category: Dialysis

  • 609 Dialysis: Palliative and End-of-Life Care


  • Belani, Sharina, Kaiser Permanente, San Rafael, California, United States
  • Mroz, Joanna, The Permanente Medical Group, Oakland, California, United States

Patients with advanced CKD and ESRD face difficult choices around extending life and managing quality of life with treatment burden. Yet, ACP choices related to dialysis therapy are rarely addressed. Nephrologists identify multiple barriers including lack of time, communication skills, and supportive tools. KPNC is an integrated health care delivery system providing care to more than 35,000 advanced CKD and 4,000 ESRD patients. KPNC Nephrology operationalized a structured ACP program called Life Care Planning (LCP) based on Respecting Choices® that follows the trajectory of CKD patients.


The KPNC LCP Nephrology program is an organized process to discuss future health care decisions and to create a written plan based on patient values and current health status. The program is operationalized with a three step staged approach using standardized communication including scripted conversations delivered by trained facilitators.

First Steps is targeted to CKD 3 and 4 patients. Next Steps is targeted to prevalent ESRD patients on dialysis focusing on critical functions and trade-offs with dialysis therapy. Advanced Steps is targeted to ESRD patients with a predicted survival of less than 12 months based on clinical indicators. Registries in our EMR are used to identify at risk nephrology patients and identify the appropriate LCP step.


Currently, 30% of our prevalent advaned CKD patients were able to both identify a decision maker for health care and provide verbal or written documentation in our EMR. Among our prevalent ESRD patients on dialysis, more than 30% of these patients have been invited to a Next Steps facilitated discussion and 16% of patients completed the discussion. Finally, 20% of highest risk ESRD patients have completed the Advanced Steps.


As an integrated health care system, KPNC is well suited to provide ongoing ACP and serious illness conversations for Nephrology patients. Future research is needed to identify effect of our LCP model at end of life including concordance with patient’s identified wishes.