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Abstract: SA-PO746

Shared-Decision Making and Renal Supportive Care: A Patient-Centered Clinical Trial

Session Information

  • Geriatric Nephrology
    October 27, 2018 | Location: Exhibit Hall, San Diego Convention Center
    Abstract Time: 10:00 AM - 12:00 PM

Category: Geriatric Nephrology

  • 1100 Geriatric Nephrology

Authors

  • Unruh, Mark L., University of New Mexico, Los Ranchos, New Mexico, United States
  • Goff, Sarah L., University of Massachusetts Medical School - Baystate, Springfield, Massachusetts, United States
  • Klingensmith, Jamie, University of Massachusetts Medical School - Baystate, Springfield, Massachusetts, United States
  • Eneanya, Nwamaka D., Massachusetts General Hospital, Boston, Massachusetts, United States
  • Chong, Kelly, University of New Mexico, Los Ranchos, New Mexico, United States
  • Germain, Michael J., Renal and Transplant Assoc of New England, Hampden, Massachusetts, United States
  • Cohen, Lewis, Baystate Medical Center, Springfield, Massachusetts, United States
Background

End-of-life (EOL) care planning in ESRD patients occurs infrequently, contributing to decreased quality of care and patient suffering. ESRD patients are much more likely to receive intensive care and less likely to receive hospice than other chronic conditions. The SDM-RSC study sought to create an easily replicable patient-centered model for EOL care planning discussions in dialysis units and to determine impacts on hospice use, EOL advanced planning, and to assess effect on patient quality of life.

Methods

We selected participants who were receiving maintenance hemodialysis and had poor prognoses using a validated prognostic instrument. Social workers and nephrologists received separate ACP training prior to inception of the intervention. Nephrologists participated in a one-hour training session that included reviews of mortality rates and ACP for hemodialysis patients. The social worker received a one-day training session and four additional telephonic “booster” sessions over two years. The intervention visit consisted of an initial patient and family meeting involving a dialysis social worker, and nephrologist; followed by ongoing contacts by the social worker and hospice contacts to dialysis units. We examined clinic-level data using an interrupted time-series design to assess changes in hospice usage over time.

Results

We recruited 125 participants from 18 dialysis units in 3 states. Our sample was 51% male, median age=70, 12% African-American, 14% American Indian, 46% White; and 37% Hispanic ethnicity. Overall clinic-level hospice usage did not vary significantly between pre- and post-intervention periods (observed average rate=25%). In participants that died during the study period, 48% stopped dialysis prior to death and 43% received hospice services. Of enrolled participants with follow-up, 75% had completed a healthcare proxy; 63% completed Medical (or Physician) Orders for Life-sustaining Treatment (MOLST/POLST). Quality of life indicators did not change significantly within 6 months of the initial meeting.

Conclusion

Clinic level effects of the intervention were not observed. There were important changes in EOL care planning for individuals, including completion of advanced care planning documents. The SDM-RSC intervention used existing staff at clinics making it practical to replicate.

Funding

  • Other U.S. Government Support