Decisions on End of Life care in Dialysis Patients

1
Decisions on End of Life care in
Dialysis Patients

• Krishna Appunu and
• Jyoti Baharani

2
Background

• The Renal MDT is often faced with making
• difficult decisions on End of life(EOL) care
• in dialysis patients
• Literature on EOL decisions and how and
• when they are made in dialysis patients is
• limited

3
National End Of Life care program

• End of Life care in advanced kidney disease
• Framework to implement quality end of
• life care.
• Recommends the use of various tools-
• GSF,PPC,LCP

4
Dialysis and CKD patients needing EOL decisions

• Conservative management patients
• Dialysis withdrawal
• Inter current acute illness malignancy
• Failed transplant patients not starting back on
• dialysis

5
End of life care in advanced kidney diseaseA
framework for implementation.
6
Aims

• To understand the decision making
• process behind End of Life Care choices
• in dialysis patients

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Methods

• Online survey tool- National
• All dialysis units which offered acute and
• chronic haemodialysis support
• Survey questionnaire was sent
• to 66 renal units in the UK

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Results

• Renal directors-36 responses received
• electronically
• Telephone follow up Renal Matrons,
• Specialist Nurses - 24 responses
• 91 response rate - 60 units

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• Nine questions included in survey
• CPR Policy
• Advance directives
• Dialysis teams contribution to EOL decisions
• Providing information leaflets
• EOL Pathways

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Do you have a written resuscitation or DNAR
policy within your unit for dialysis patients?
Yes - 34 No - 26
11
Does this policy apply to Acute Haemodialysis
patients?
Yes - 33 No - 24 Skipped question - 3
12
Does this policy apply to chronic dialysis
patients ?
Yes - 32 No - 21 Skipped question - 7
13
Do you provide information leaflets with regards
to CPR, Advance care planning DNAR for your
patients?
Yes -12 No - 48
14
Do the dialysis team make active decisions
regarding patients resuscitation status as part
of the monthly review/QUALY meetings?
Yes - 19 No - 41
15
Do all the chronic dialysis patients have a
documented CPR or DNAR status within their care
plan?
Yes - 28 No - 32
16
Do your dialysis patients have documented
Advance directives/EOL preferences within their
dialysis care plan?
Yes - 39 No - 20 Skipped - 1
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• End of Life pathways
• Which tools do you use for End of life planning
  in your unit?
• Liverpool care pathway - LCP
• Gold standard framework - GSF
• Supportive care pathway - SCP
• Preferred priorities of care - PPC

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Current End Of Life Care pathways
Liverpool care pathway- Developed in 1990
Liverpool Royal Hospital Marie Curie
Hospice-12th Version 2009 Preferred priorities
of care- Person held document that facilitates
individual choices in EOL decisions. Dec
2007 Gold standard framework-2000. Developed by
Dr Keri Thomas for primary care. 2004- Nursing
Homes. 2006- Acute Hospitals Supportive care
pathway-Pan Birmingham Palliative Care Network
2006
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Liverpool care pathway LCP
Response count - 58 Yes - 55 No - 3
20
Preferred priorities of care
Total responses - 49 Yes - 11 No - 38
21
Supportive care pathway
Total responses - 53 Yes - 28 No - 25
22
Gold standard framework
Response count - 51 Yes - 22 No - 29
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End of life care pathways
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YORK DGH

• Answered yes to all the questions
• Consultant with special interest in EOL care
• in dialysis patients
• Specialist palliative nurse with renal interest

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Summary

• Most units had a CPR policy however
  implementation
• was poor.
• Very few units provided information leaflets on
  CPR/EOL
• decision.
• Renal MDT contributed very little in QUALY
  meetings with
• regards to CPR/EOL decisions.
• LCP pathway was the predominantly used EOL tool.
• A uniform policy should be adopted across all
  units in
• accordance with the national EOL care
  strategy.

26

• With thanks to all the renal units that completed
  the survey