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S 28 Parallel Session
Programme of the Session
Title: End of life care
GS: Cristiana Dente (Italy)
What is the best end-of-life care? The experience of Biella HD center, Italy
O 72
Advance care planning for haemodialysis patients
Kim Blair (UK)
O 73
Mourning reactions among dialysis patients
Erzsebet Horvath (Hungary)
O 74
Renal palliative care – where to after the PACKS study?
Helen Noble (UK)
Abstracts
GUEST SPEAKER
What is the best end-of-life care? The experience of Biella HD center, Italy
C. Dente1
1UO Dialisi, ASL Biella, Biella, Italy
Background
According to the international literature, the prognosis in dialysis patients over 65 appears to be similar to that of colorectal cancer patients and slightly better than the one in patients with lung cancer. The benefits of dialysis, in terms of survival, seem minimal in over 75 year olds: 8,3 months with dialysis treatment vs. 6,3 months with palliative care, namely survival increased by 16% with twelve months dialysis. They are elderly patients with high levels of comorbidity, high clinical symptomatology, and low quality of life. Due to some experienced difficulties approaching end-of-life care, doctors and nurses at the Dialysis Center in Biella (Italy) started casting doubts on the appropriateness of dialysis in terminally ill patients.
Objectives
The aim of this project is to create a palliative care service for ESRD patients in Biella Hospital (Italy).
Methods
At our HD Center we began to collaborate with palliativist physicians by implementing Cohen Predictive Index in order to quickly find out about terminally ill patients.
Results
Palliative care patients, whose treatment was suspended, have exponentially grown over the years and in some cases our Nephrology Team managed to provide home peritoneal dialysis, as well.
Conclusion/Application to practice
Thanks to some training courses, the Dialysis Team now manages to provide terminally ill patients with better care and shows improved skills when it comes to delivering bad news. Through a questionnaire the staff emphasized the importance of end-of-life care as well as the emotional involvement this issue entails.
BIOGRAPHY OF THE GUEST SPEAKER
O 72
Advanced care planning for haemodialysis patients
K. Blair1, A.M. Habib2, J. Mc Nicholas2, L. Baker1
1Farnborough Dialysis Unit, Fresenius Medical Care, Farnborough, United Kingdom; 2Renal Unit, St Helier Hospital, Carshalton, Surrey, Carshalton, United Kingdom
Background
It is recognised that most patients would prefer to die at home but most dialysis patients die in hospital. It appeared that end of life care had somewhat been neglected in this patient population
Objectives
The objective was to determine whether "Advanced Care Planning" (ACP) could result in the following
1. Empowering the patient and family
2. Improvement in end of life care and measurable advances in patient experiences
3. Fewer hospital admissions or less of treatments which are life prolonging
4. Better provision of service relating to individual patient needs
Methods
Individual patients were identified as having high co-morbidiites, often in parallel with advanced age, with the likelihood of dying in the next year. A voluntary process of discussion regarding their future care between the individual patient and thein care providers was implemented. An ACP was utilised to ensure that patients' relatives, haemodialysis staff and the community teams knew the patients' wishes
Results
The professional interviewer needed to be sensitive to cultural interpretations, individual patient views which change over time and acknowledge that patients and relatives may have a clash of view points. The discussion can be seen as a bad news interview. The ACP allowed a patient, his/her family with the support of the above teams to implement his/her wishes.
Conclusion/Application to practice
Initially 8 patients were identified, and now this has been increased to 25. The referring hospital has decided to roll out the programme to all of its satellite units as a standard of good practice.
O 73
Mourning reactions among dialysis patients
E. Horvath1, M. Varkonyi1, T. Szabo1
1Dialysis Centre 14, B. Braun Avitum Hungary, Kistarcsa, Hungary
Background
People can mourn not only over the loss of a family member but also over the loss of their own health. Going onto dialysis is a traumatic event for every patient with chronic kidney disease. Even if they received pre-dialysis care and the start of the treatment was planned, it always causes a negative change in life-style and quality of life.
Objectives
We have interviewed patients at our dialysis unit about their mourning reactions.
Methods
The questioner was based on the work of Dr Hegedüs. Patients were interviewed at initiation of dialysis and also several month later on dialysis.
Results
We found that mourning over their disease is very common reaction among chronic dialysis patients. In some cases we saw a delayed reaction as the patient needed to focus on the decision making and the procedures around the start of the treatment. Reaction in these cases occured weeks later when they had to settle into the new situatiuon. We could observe the different stages of the reaction (denial, anger, haggling, depression and acceptance) even half a year after initiation of theatment. The stages of haggling and depression lastied longer and alternated in many cases.
Conclusion/Application to practice
After initiation of dialysis many patients need psychological support in order to cope with the new life-situation. Psychological services should be involved in pre-dialysis care to prepare patients for oncoming treatment and lessen the burden. Patients new to dialysis could also benefit from peer support programmes.
O 74
Renal palliative care - where to after the PACKS study?
H. Noble1
1School of Nursing and Midwifery, Queen's University Belfast, Belfast, United Kingdom
The PAlliative Care in chronic Kidney diSease study (PACKS study) is examining quality of life, decision making and decisional conflict, costs and mortality in patients with advanced chronic kidney disease who have opted for palliative care. It is also exploring the impact of the decision on the quality of life of carers. The study includes adult patients with end stage (stage 5) chronic kidney disease who have opted for palliative care, adult carers of these patients and renal physicians/clinical nurse specialists who have experience of treating patients with end stage chronic kidney disease who have opted for palliative care.
Early initial findings relate to clinician perspectives on patient decisional conflict, in making complex decisions between dialysis and conservative management. Interviews were conducted with nephrologists and clinical nurse specialists across 10 renal centres in the UK. Themes with associated subthemes include “Frequent changing of mind regarding treatment options,” “A paternalistic approach to decision-making and “Intricacy of the decision”. These findings will be presented and recommendations for future research and education made. Clinicians need to take a more patient centered approach to decision-making. Interventions aimed at increasing understanding of renal disease and its treatments may reduce decisional conflict and raise decisional quality and it is recommended these are tested in the renal specialty.