Improving Advance Care Planning in Chronic Kidney Disease

Abstract

As the age of dialysis patients increases, it is important to increase attention to advance-care planning (ACP) in the nephrology community. There are numerous ways to accomplish ACP, but it is important to note that having an advance directive (medical power of attorney or living will) does not mean that the clinician has a clear understanding of a patient's perceptions. The goal of this study was to evaluate nephrologists’ views of ACP goals-of-care and end-of-life (EOL) discussions and improve ACP in chronic kidney disease (CKD). A needs assessment was created to identify and review barriers and strengths that could inform efforts to increase ACP within a large nephrology practice. A survey of nephrologists from a large practice in Texas regularly seeing patients aged 65 and older (N = 31) was conducted. Two-thirds of nephrologists, compared to 50% of other primary care practitioners (PCPs)/other specialists, feel that it is important to have goals-of-care conversations with patients. Eighty-six percent of the nephrologists had not had a conversation with their own healthcare provider about wishes for care at the end of life, in comparison with 52% of PCPs/other specialists. When nephrologists responded at a higher percentage, 6 out of 7 of those responses were independent from PCPs/other specialists. Nearly three-quarters (74%) of nephrologists thought it was their responsibility to initiate ACP, but also felt that they had not had training fortalking to patients and families about ACP. A salient observation is the concern expressed by nephrologists over disagreement between family members and patients, coupled with time constraints and comfort level in discussing goals of care. These factors make licensed and experienced social workers ideal partners to facilitate early and repeated ACP discussions with patients and family members, which lead to greater physician-patient engagement and cost-effective care. By having ongoing ACP conversations with patients and family members prior to late stage CKD, nephrologists could more often achieve the patient- and healthcare-valued outcome of goal-concordant-care. Goal-concordant care places the patient's values and wishes at the center of care