Decisions on End of Life care in Dialysis Patients Krishna Appunu and Jyoti Baharani

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

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

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

End of life care in advanced kidney disease:A framework for implementation.

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

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

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

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

Do you have a written resuscitation or DNAR policy within your unit for dialysis patients? Yes - 34 No - 26

Does this policy apply to Acute Haemodialysis patients? Yes - 33 No - 24 Skipped question - 3

Does this policy apply to chronic dialysis patients ? Yes - 32 No - 21 Skipped question - 7

Do you provide information leaflets with regards to CPR, Advance care planning & DNAR for your patients? Yes -12 No - 48

Do the dialysis team make active decisions regarding patients resuscitation status as part of the monthly review/QUALY meetings? Yes - 19 No - 41

Do all the chronic dialysis patients have a documented CPR or DNAR status within their care plan? Yes - 28 No - 32

Do your dialysis patients have documented Advance directives/EOL preferences within their dialysis care plan? Yes - 39 No - 20 Skipped - 1

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

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 Developed by Dr Keri Thomas for primary care Nursing Homes Acute Hospitals Supportive care pathway-Pan Birmingham Palliative Care Network 2006

Liverpool care pathway [LCP] Response count - 58 Yes - 55 No - 3

Preferred priorities of care Total responses - 49 Yes - 11 No - 38

Supportive care pathway Total responses - 53 Yes - 28 No - 25

Gold standard framework Response count - 51 Yes - 22 No - 29

End of life care pathways

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

 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. Summary

With thanks to all the renal units that completed the survey