Kidney Week

Abstract: FR-OR29

Improving Supportive Care of Seriously Ill Dialysis Patients with Goals-of-Care Conversations

Session Information

• Hemodialysis and Home Hemodialysis: Research Abstracts
  October 23, 2020 | Location: Simulive
  Abstract Time: 05:00 PM - 07:00 PM

Category: Dialysis

• 701 Dialysis: Hemodialysis and Frequent Dialysis

Authors

• Moss, Alvin H., West Virginia University Health Sciences Center, Morgantown, West Virginia, United States

Alvin H. Moss, MD



Dr. Moss is a Professor of Medicine in the Sections of Nephrology and Palliative Medicine at the West Virginia University School of Medicine. He serves as Chair of the Coalition for Supportive Care of Kidney Patients. He led the writing of the first and second editions of the clinical practice guideline, Shared Decision-Making in the Appropriate Initiation of and Withdrawal from Dialysis. He serves on the editorial boards of the Clinical Journal of the American Society of Nephrology and the Journal of Pain and Symptom Management. He received the Distinguished Service Award from the Renal Physicians Association in 2011 and the Medal of Excellence Award from the American Association of Kidney Patients in 2015. He is a co-principal investigator on a grant funded by the Gordon and Betty Moore Foundation to integrate supportive care into the treatment of patients with advanced CKD and ESRD. His research interests include dialysis ethics and improving care at the end of life. He is a graduate of Harvard University and the University of Pennsylvania School of Medicine.

• Aldous, Annette, George Washington University School of Public Health and Health Services, The George Washington University Milken Institute of Public Health, Washington, District of Columbia, United States

Annette Aldous,

• Harbert, Glenda, The George Washington University School of Nursing, Ashburn, Virginia, United States

Glenda Harbert,

• Nicklas, Amanda C., The George Washington University School of Nursing, Ashburn, Virginia, United States

Amanda C. Nicklas,

• Diamond, Louis, The George Washington University School of Nursing, Ashburn, Virginia, United States

Louis Diamond,

• Armistead, Nancy, The George Washington University School of Nursing, Ashburn, Virginia, United States

Nancy Armistead,

• Lupu, Dale, The George Washington University School of Nursing, Ashburn, Virginia, United States

Dale Lupu,

Background

Dialysis patients are frequently known to receive unwanted high intensity end-of-life care. Families rate the quality of this care lower than families of patients with other chronic diseases.The purpose of this study was to test the feasibility of a supportive care intervention--the Pathways Project, an evidence-based change package of best practices--to identify seriously ill patients (SI), engage them in goals of care discussions, and track outcomes for patient goal concordance.

Methods

Pathways researchers recruited 10 dialysis centers with 1,546 patients. Dialysis staff screened patients with the surprise question (SQ)-"Would I be surprised if this patient died in the next 6-12 months?"- to identify those who were SI and recorded patient outcomes including the number screened, SI, goals of care conversations, hospitalizations, referred to hospice, death, and place of death. An odds ratio was calculated for the odds of SI dying versus those who were not SI, and one-sided Cochran-Armitage trend tests were used to assess for increasing goals of care conversations and deaths at home. The study was interrupted at 9 months due to COVID-19.

Results

On average, 98.8% of patients were screened monthly, and 18.4% were identified as SI. Of 114 patients who died, the SI constituted 66% of deaths though only 18.4% of patients. The mortality for the SI was 27% versus 3% for those who were not, and the odds ratio for SI dying was 11.22 (95% CI 7.42 to 16.98, P < .0001). Dialysis interdisciplinary teams implemented site-specific approaches to adding goals of care conversations into usual workflow; the number conducting conversations with SI within 30 days of hospital discharge increased from 30% to 80% (P=.02). The proportion of the patients who died at home in the last 2 months was higher than baseline (32.6% vs 18.8%), but a trend was not yet evident (P=.12).

Conclusion

The Pathways intervention is feasible to implement supportive care best practices into existing workflow of dialysis centers. It takes time for teams to get comfortable with new processes and communication approaches; after 9 months more centers were conducting goals of care conversations and more patients were dying at home. Future research is needed to determine if the Pathways intervention results in outcomes more aligned with patient preferences.

Funding

• Private Foundation Support