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Abstract: FR-PO911

Improving Advanced Care Planning in Maintenance HD Patients with ESRD

Session Information

Category: Dialysis

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


  • El-Khoury, Bashir, University of Texas Health Science Center San Antonio, San Antonio, Texas, United States
  • Takkar, Chandandeep, University of Texas Health Science Center San Antonio, San Antonio, Texas, United States

More than 80,000 Americans die every year while receiving maintenance dialysis therapy for ESRD. The adjusted mortality rate of maintenance dialysis patients is nearly twice that of adults with cancer and more than twice that of adults with CHF or stroke. Rates of hospitalization and ICU admission during last month of life are also higher in ESRD patients. Although studies have shown that dialysis patients with a treatment-limiting advance directive were less likely to be hospitalized, receive intensive procedures, and die in the hospital, advanced care planning
(ACP) or completion of Advance Directives (AD)/Medical Power of Attorneys (MPOA) is lacking in the ESRD population compared to other chronic illnesses.


We conducted a pilot quality improvement project aimed at improving ACP in the maintenance HD community. Our goal was to increase the percentage of MWF second shift hemodialysis patients at University Dialysis Northwest (one of four dialysis units affiliated with us) with AD/MPOAs on file by 25% between November 2016 and February 2017. An inter-disciplinary team was convened. We surveyed our patients to obtain baseline information on current rates of AD/MPOA completion, knowledge of ACP, desire to participate in ACP, and identify barriers to completion. We collaborated with the Department of Palliative Medicine and implemented a series of interventions aimed towards facilitating the completion of ADs/MPOAs in our patients.


We were able to increase the percentage of completed ADs/MPOAs to 29.2% from a baseline of 4.2% during our timeline. We are currently implementing measures including dedicated training in ACP for dialysis staff at all our outpatient dialysis facilities, incorporating ACP into interdisciplinary team meetings, establishing on-site notaries, and providing patient education in order to sustain results and expand the program to all UHS outpatient HD units.


Advance care planning is a vital aspect of patient-centered care at the end of life. Unfortunately it is lacking in the maintenance dialysis patient population due to a variety of cultural, provider and institutional barriers. We demonstrated that a comprehensive multidisciplinary approach to advance care planning improves AD/MPOA completion rates in our patient population.