Serious Illness Conversations in ESRD

Abstract

Dialysis-dependent ESRD is a serious illness with high disease burden, morbidity, and mortality. Mortality in the first year on dialysis for individuals over age 75 years old approaches 40%, and even those with better prognoses face multiple hospitalizations and declining functional status. In the last month of life, patients on dialysis over age 65 years old experience higher rates of hospitalization, intensive care unit admission, procedures, and death in hospital than patients with cancer or heart failure, while using hospice services less. This high intensity of care is often inconsistent with the wishes of patients on dialysis but persists due to failure to explore or discuss patient goals, values, and preferences in the context of their serious illness. Fewer than 10% of patients on dialysis report having had a conversation about goals, values, and preferences with their nephrologist, although nearly 90% report wanting this conversation. Many nephrologists shy away from these conversations, because they do not wish to upset their patients, feel that there is too much uncertainty in their ability to predict prognosis, are insecure in their skills at broaching the topic, or have difficulty incorporating the conversations into their clinical workflow. In multiple studies, timely discussions about serious illness care goals, however, have been associated with enhanced goal-consistent care, improved quality of life, and positive family outcomes without an increase in patient distress or anxiety. In this special feature article, we will () identify the barriers to serious illness conversations in the dialysis population, () review best practices in and specific approaches to conducting serious illness conversations, and () offer solutions to overcome barriers as well as practical advice, including specific language and tools, to implement serious illness conversations in the dialysis population.

Association of Initiation of Maintenance Dialysis with Functional Status and Caregiver Burden

“…Moreover, the effect of functional loss is highly dependent on personal values and patient preferences. Thus, it is important to use the predialysis phase to explore an individual's health goals (e.g., living at home, engage in social activities) and current quality of life (46). This could improve shared decision making regarding dialysis and conservative management.…”

What is palliative care? Perceptions of healthcare professionals

“…Ho and colleagues found that physicians felt uncomfortable with death and dying and perceived that other professionals were better trained to conduct these conversations. This is in line with a recent study involving dialysis care physicians . Reasons for hesitation were that they felt uncertain about their skills to handle the conversations.…”

Single Cell Profiling Reveals Sex, Lineage and Regional Diversity in the Mouse Kidney

“…Though a kidney transplant is an effective solution, donor supply is well short of demand and transplant is not an option for many (Crews et al, 2019). End-stage renal disease is treated with dialysis, but dialysis is associated with high rates of morbidity and mortality (Mandel et al, 2016). Synthetic approaches to generate new kidney structures require a detailed understanding of kidney cell types and their actions (Oxburgh et al, 2017).…”