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Abstract: TH-PO777

The Effectiveness of SPIRIT in Preparing Patients on Dialysis and Their Surrogates for End-of-Life Decision Making: A Pragmatic Trial

Session Information

Category: Geriatric Nephrology

  • 1200 Geriatric Nephrology

Authors

  • Song, Mi-Kyung, Emory University, Atlanta, Georgia, United States
  • Metzger, Maureen J., University of Virginia, Charlottesville, Virginia, United States
  • Manatunga, Amita, Emory University, Atlanta, Georgia, United States
  • Wu, Emily, Emory University, Atlanta, Georgia, United States
  • Englert, Jacob R., Emory University, Atlanta, Georgia, United States
  • Kshirsagar, Abhijit V., University of North Carolina System, Chapel Hill, North Carolina, United States
  • Lea, Janice P., Emory University, Atlanta, Georgia, United States
  • Plantinga, Laura, Emory University, Atlanta, Georgia, United States
  • Abdel-Rahman, Emaad M., University of Virginia, Charlottesville, Virginia, United States
  • Ward, Sandra E., University of Wisconsin-Madison, Madison, Wisconsin, United States
  • Jhamb, Manisha, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
  • Laszlo, Mary C., Emory University, Atlanta, Georgia, United States
  • Benloukil, Souad, University of Virginia, Charlottesville, Virginia, United States
  • Turberville-Trujillo, Linda, Emory University, Atlanta, Georgia, United States

Group or Team Name

  • SPIRIT Trial Investigators
Background

SPIRIT (Sharing Patient’s Illness Representations to Increase Trust), a patient and family-centered advance care planning intervention with established efficacy in preparing patients on dialysis and their surrogates (dyads) for difficult end-of-life decision making, was tested for its real-world effectiveness when implemented as part of routine dialysis care.

Methods

In this cluster randomized trial, 39 outpatient dialysis clinics across 5 states (GA, NC, VA, PA, NM) were randomized by state and clinic size (22 intervention and 17 usual care). Each clinic selected at least one SPIRIT Champion (SWs, RNs, or APRNs) to identify potential patients and, in the intervention clinics, to conduct SPIRIT sessions with the dyads. SPIRIT included a 45- to 60-min. counseling session to help the patient articulate his/her values and to help the dyad understand likely end-of-life decision-making situations. A brief follow-up session was provided as needed. The preparedness outcomes (dyad congruence, patient decisional conflict, surrogate decision-making confidence, and a composite of congruence and surrogate confidence) were assessed at baseline and 2 weeks postintervention by phone.

Results

426 patients and their chosen surrogates (231 dyads from intervention and 195 from usual care clinics) completed the baseline measures and were included in ITT analyses using GEEs. The sample included 72% dyads from minority groups, 51.2% women; patients were 61.9 years old (SD=12.7) and on dialysis for 4.6 years (SD=5.2) and 16% had an advance directive. Changes in dyad congruence (OR=1.6, p=.01), patient decisional conflict (b=-.1, p<.001), and the composite outcome (OR=1.6, p=.03) were better in SPIRIT than usual care, and these treatment effects were greater in non-white dyads,

Conclusion

SPIRIT was associated with improvements in dyad preparation for end-of-life decision making in a real-world dialysis care setting, with treatment effects comparable to those seen in previous efficacy trials of SPIRIT.

Funding

  • Other NIH Support