Advance care planning (ACP), and its impact in the renal unit

Abstract

ACP improves end-of-life care and patient/family satisfaction. ACP was implemented in the nephrology department of a university hospital in 2010. Patient and ACP activity data was collected prospectively to audit the ACP process and assess its impact on patient outcome. Data was collected from 1/2/2010 to 1/8/2011, including review of deceased patients' files. 197 nephrology patients were seen (median age 69 (21-91), 68% male). 81% were receiving dialysis, 8% pre-dialysis, 7% post-transplant and 4% were non-dialysis patients. 63% completed documentation: 16% appointed a substitute decision maker only, 3% an advance care plan only, or 81% did both. Of those who completed an advance care plan 69% stated they did not want CPR, 17% did not want life-prolonging treatment at all, and 78% only wanted life-prolonging treatment other than dialysis if their specified minimal outcome was anticipated. 31/197 (16%) patients (median age 80) died: 29/31 were dialysis patients (median dialysis duration prior to death 4.2 years). 72 % of deceased dialysis patients had dialysis electively ceased prior to death (median time withdrawal to death 2 days), 7% patients died suddenly outside of hospital, 7% patients specifically requested dialysis continue, but died, and 14% patients had a cardiac arrest during dialysis and died. Deceased patients wishes were known and respected in 68%, unknown in 19%, or known and not respected in 13%. Whilst ACP facilitates patient-initiated dialysis withdrawal it usually occurs late and too many patients are receiving unwanted treatment.