title: Nephrologist-Facilitated Advance Care Planning for Hemodialysis Patients: A Quality Improvement Project.
abstract: BACKGROUND
  The Renal Physicians Association's clinical practice guideline recommends that physicians address advance care planning with dialysis patients. However, data are lacking about how best to implement this recommendation.
  
  
  METHODS
  Quality improvement project.
  
  
  METHODS
  Nephrologists caring for patients treated with maintenance hemodialysis at 2 dialysis facilities identified patients who might benefit most from advance care planning using the "surprise" question ("Would I be surprised if this patient died in the next year?").
  
  
  METHODS
  Patients identified with a "no" response to the surprise question were invited to participate in nephrologist-facilitated advance care planning, including completion of a Medical Orders for Life-Sustaining Treatment (MOLST) form.
  
  
  RESULTS
  Change in MOLST completion rate and identification of preferences for limits on life-sustaining treatment.
  
  
  METHODS
  Pre- and postintervention code status, MOLST completion rate, and vital status at 1 year.
  
  
  RESULTS
  Nephrologists answered "no" to the surprise question for 50 of 201 (25%) hemodialysis patients. Of these, 41 (82%) patients had a full-code status and 9 (18%) had a do-not-resuscitate (DNR) status. Encounters lasted 15 to 60 minutes. Following the encounter, 21 (42%) patients expressed preference for a DNR status and 29 (58%) maintained full-code status (P=0.001). The MOLST completion rate increased from 10% to 90%. One-year survival for patients whose nephrologists answered "no" to the surprise question was 58% compared to 92% for those with a "yes" answer (P<0.001).
  
  
  CONCLUSIONS
  Sample size and possible nonrepresentative dialysis population.
  
  
  CONCLUSIONS
  Nephrologist-facilitated advance care planning targeting hemodialysis patients with limited life expectancy led to significant changes in documented patient preferences for cardiopulmonary resuscitation and limits on life-sustaining treatment. These changes demonstrate the benefit of advance care planning with dialysis patients and likely reflect better understanding of end-of-life treatment options.
authors.affiliation: Division of Nephrology, Department of Medicine, Tufts Medical Center, Boston, MA; Department of Medicine, Tufts University School of Medicine, Boston, MA.
authors.forename: Osama W
authors.initials: OW
authors.lastname: Amro
authors.affiliation: Division of Nephrology, Department of Medicine, Tufts Medical Center, Boston, MA; Department of Medicine, Tufts University School of Medicine, Boston, MA.
authors.forename: Malar
authors.initials: M
authors.lastname: Ramasamy
authors.affiliation: Department of Medicine, Tufts University School of Medicine, Boston, MA; Division of Nephrology, Department of Medicine, St Elizabeth Medical Center, Boston, MA.
authors.forename: James A
authors.initials: JA
authors.lastname: Strom
authors.affiliation: Division of Nephrology, Department of Medicine, Tufts Medical Center, Boston, MA; Department of Medicine, Tufts University School of Medicine, Boston, MA.
authors.forename: Daniel E
authors.initials: DE
authors.lastname: Weiner
authors.affiliation: Department of Medicine, Tufts University School of Medicine, Boston, MA; Division of Nephrology, Department of Medicine, St Elizabeth Medical Center, Boston, MA. Electronic address: bertrand.jaber@steward.org.
authors.forename: Bertrand L
authors.initials: BL
authors.lastname: Jaber
mesh_terms: D032722:Advance Care Planning; D000368:Aged; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D000072104:Nephrologists; D058996:Quality Improvement; D006435:Renal Dialysis
keywords: Advance care planning; cardiopulmonary resuscitation; code status; do not resuscitate (DNR); end-of-life care; end-stage renal disease (ESRD); hemodialysis; life expectancy; medical orders for life-sustaining treatment (MOLST); physician orders for life-sustaining treatment (POLST); quality improvement; shared decision making