Nephrology Provider Prognostic Perceptions and Care Delivered to Older Adults with Advanced Kidney Disease

Clinical journal of the American Society of Nephrology: CJASN

Aihua Bian¹  Huzaifah Salat⁵  Edmond Kabagambe⁸ 

[1] and..¶General Internal Medicine, Public Health and Palliative Medicine, Vanderbilt University Medical Center, Nashville, Tennessee;and..‖Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee;**Division of Nephrology, Meharry Medical College, Nashville, Tennessee..Divisions of *Nephrology and Hypertension,..Divisions of *Nephrology and Hypertension,..;Divisions of *Nephrology and Hypertension,..Divisions of *Nephrology and Hypertension,..Divisions of *Nephrology and Hypertension,..‡Department of Medicine, School of Medicine and Health Science, University of North Dakota, Grand Forks, North Dakota;¶General Internal Medicine, Public Health and Palliative Medicine, Vanderbilt University Medical Center, Nashville, Tennessee;‖Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee;†Vanderbilt Center for Kidney Disease, Division of Nephrology and Hypertension, Nashville, Tennessee

关键词: chronic kidney disease;    advance care planning;    conservative management;    surprise question;    shared decision making;    end of life care;    living will;    durable power of attorney;    renal replacement therapy planning;    medical order;    Hospices;    Prospective Studies;    nephrology;    Uncertainty;    Nephrologists;    Conservative Treatment;    Follow-Up Studies;    Advance Care Planning;    Terminal Care;    Hospice Care;    kidney;    Renal Insufficiency, Chronic;    Documentation;   

DOI  :  10.2215/CJN.03830417

学科分类：泌尿医学

来源: American Society of Nephrology

【 摘 要 】

Background and objectives Prognostic uncertainty is one barrier that impedes providers in engaging patients with CKD in shared decision making and advance care planning. The surprise question has been shown to identify patients at increased risk of dying.Design, setting, participants, & measurements In our prospective observational study, 488 patients ≥60 years of age with CKD stage 4 or 5 were enrolled. Binary surprise question (i.e., “Would you be surprised if this patient died in the next 12 months?”) responses were recorded, and dialysis planning preferences, presence of advance care planning documentation, and care preceding death were abstracted.Results The median patient age was 71 (65–77) years old. Providers responded no and yes to the surprise question for 171 (35%) and 317 (65%) patients, respectively. Median follow-up was 1.9 (1.5–2.1) years, during which 18% of patients died (33% of surprise question no, 10% of surprise question yes; P<0.001). In patients with a known RRT preference (58%), 13% of surprise question no participants had a preference for conservative management (versus 2% of yes counterparts; P<0.001). A medical order (i.e., physician order for life-sustaining treatment) was documented in 13% of surprise question no patients versus 5% of yes patients (P=0.004). Among surprise question no decedents, 41% died at home or hospice, 38% used hospice services, and 54% were hospitalized in the month before death. In surprise question yes decedents, 39% died at home or hospice (P=0.90 versus no), 26% used hospice services (P=0.50 versus no), and 67% were hospitalized in the month before death (P=0.40 versus surprise question no).Conclusions Nephrologists’ prognostic perceptions were associated with modest changes in care, highlighting a critical gap in conservative management discussions, advance care planning, and end of life care among older adults with CKD stages 4 and 5 and high-risk clinical characteristics.Podcast This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2017_09_18_CJASNPodcast_17_11.mp3

【 授权许可】

CC BY