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.

Study design: Quality improvement project.

Settings & participants: 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?").

Quality improvement plan: 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.

Outcomes: Change in MOLST completion rate and identification of preferences for limits on life-sustaining treatment.

Measurements: 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).

Limitations: 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.

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.

Figure 1

Key elements of the advance care planning quality improvement program. The program started by meeting with stakeholders (social worker, nurse, physician), followed by training of physicians on advance care planning (ACP) and completion of the Massachusetts MOLST form who conducted the dedicated clinical encounters with selected patients who had with a limited life expectancy. This educational cycle is repeated annually.

Figure 2

Quality improvement project flow diagram. *The predicted survival expectation is based on the response of the nephrologist caring for the patient to the following ‘surprise’ question: “Would I be surprised if this patient died in the next year?” (21). A ‘yes’ answer to the question indicates a physician-predicted life expectancy of > 1 year; a ‘no’ answer to the question indicates a physician-predicted life expectancy ≤ 1 year. DNR denotes Do Not Resuscitate. The patient’s code status significantly changed following the dedicated clinical encounter on advance care planning, with an increase in the DNR order status from 18% to 42% (p = 0.001 by the McNemar’s test).

Figure 3

Kaplan-Meier survival plot depicting cumulative mortality among patients with shorter (solid line) and longer (dashed line) physician-estimated life expectancy. The analysis is censored at 12 months. p < 0.001 by the log-rank test. The physician-estimated life expectancy is based on the physician response to the following ‘surprise’ question: “Would I be surprised if this patient died in the next year?” (21).