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Limited implementation of palliative care practices in hemodialysis may contribute to end-of-life care that is intensive and not patient centered. We determined whether a learning collaborative for hemodialysis center providers improved delivery of palliative care best practices.Ten US hemodialysis centers participated in a pre-post study targeting seriously ill patients between April 2019 and September 2020. Three practices were prioritized: screening for serious illness, goals of care discussions, and use of a palliative dialysis care pathway. The collaborative educational bundle consisted of learning sessions, communication skills training, and implementation support. The primary outcome was change in the probability of complete advance care planning documentation among seriously ill patients. Health care utilization was a secondary outcome, and implementation outcomes of acceptability, adoption, feasibility, and penetration were assessed using mixed methods.One center dropped out due to the coronavirus disease 2019 pandemic. Among the remaining nine centers, 20% (273 of 1395) of patients were identified as seriously ill preimplementation, and 16% (203 of 1254) were identified as seriously ill postimplementation. From the preimplementation to postimplementation period, the adjusted probability of complete advance care planning documentation among seriously ill patients increased by 34.5 percentage points (95% confidence interval, 4.4 to 68.5). There was no difference in mortality or in utilization of palliative hemodialysis, hospice referral, or hemodialysis discontinuation. Screening for serious illness was widely adopted, and goals of care discussions were adopted with incomplete integration. There was limited adoption of a palliative dialysis care pathway.A learning collaborative for hemodialysis centers spanning the coronavirus disease 2019 pandemic was associated with adoption of serious illness screening and goals of care discussions as well as improved documentation of advance care planning for seriously ill patients.Pathways Project: Kidney Supportive Care, NCT04125537.

Current care models for older patients with kidney failure in the United States do not incorporate supportive care approaches. The absence of supportive care contributes to poor symptom management and unwanted forms of care at the end of life. Using an Institute for Healthcare Improvement Collaborative Model for Achieving Breakthrough Improvement, we conducted a focused literature review, interviewed implementation experts, and convened a technical expert panel to distill existing evidence into an evidence-based supportive care change package. The change package consists of 14 best-practice recommendations for the care of patients seriously ill with kidney failure, emphasizing three key practices: systematic identification of patients who are seriously ill, goals-of-care conversations with identified patients, and care options to respond to patient wishes. Implementation will be supported through a collaborative consisting of three intensive learning sessions, monthly learning and collaboration calls, site data feedback, and quality-improvement technical assistance. To evaluate the change package’s implementation and effectiveness, we designed a mixed-methods hybrid study involving the following: (1) effectiveness evaluation (including patient outcomes and staff perception of the effectiveness of the implementation of the change package); (2) quality-improvement monitoring via monthly tracking of a suite of quality-improvement indicators tied to the change package; and (3) implementation evaluation conducted by the external evaluator using mixed methods to assess implementation of the collaborative processes. Ten dialysis centers across the country, treating approximately 1550 patients, will participate. This article describes the process informing the intervention design, components of the intervention, evaluation design and measurements, and preliminary feasibility assessments. Clinical Trial registry name and registration number: Pathways Project: Kidney Supportive Care, NCT04125537.

PURPOSE OF REVIEW: Using case vignettes, we highlight challenges in communication, prognostication, and medical decision-making that have been exacerbated by the coronavirus disease-19 (COVID-19) pandemic for patients with kidney disease. We include best practice recommendations to mitigate these issues and conclude with implications for interdisciplinary models of care in crisis settings. RECENT FINDINGS: Certain biomarkers, demographics, and medical comorbidities predict an increased risk for mortality among patients with COVID-19 and kidney disease, but concerns related to physical exposure and conservation of personal protective equipment have exacerbated existing barriers to empathic communication and value clarification for these patients. Variability in patient characteristics and outcomes has made prognostication nuanced and challenging. The pandemic has also highlighted the complexities of dialysis decision-making for older adults at risk for poor outcomes related to COVID-19. SUMMARY: The COVID-19 pandemic underscores the need for nephrologists to be competent in serious illness communication skills that include virtual and remote modalities, to be aware of prognostic tools, and to be willing to engage with interdisciplinary teams of palliative care subspecialists, intensivists, and ethicists to facilitate goal-concordant care during crisis settings.

Using case vignettes, we highlight challenges in communication, prognostication, and medical decision-making that have been exacerbated by the coronavirus disease-19 (COVID-19) pandemic for patients with kidney disease. We include best practice recommendations to mitigate these issues and conclude with implications for interdisciplinary models of care in crisis settings.Certain biomarkers, demographics, and medical comorbidities predict an increased risk for mortality among patients with COVID-19 and kidney disease, but concerns related to physical exposure and conservation of personal protective equipment have exacerbated existing barriers to empathic communication and value clarification for these patients. Variability in patient characteristics and outcomes has made prognostication nuanced and challenging. The pandemic has also highlighted the complexities of dialysis decision-making for older adults at risk for poor outcomes related to COVID-19.The COVID-19 pandemic underscores the need for nephrologists to be competent in serious illness communication skills that include virtual and remote modalities, to be aware of prognostic tools, and to be willing to engage with interdisciplinary teams of palliative care subspecialists, intensivists, and ethicists to facilitate goal-concordant care during crisis settings.

National and international nephrology organizations have identified substantial unmet supportive care needs of patients with kidney disease and issued recommendations. In the United States, the most recent comprehensive effort to change kidney care, the Advancing American Kidney Health Initiative, does not explicitly address supportive care needs, although it attempts to implement more patient-centered care. This Perspective from the leaders of the Coalition for Supportive Care of Kidney Patients advocates for urgent policy changes to improve patient-centered care and the quality of life of seriously ill patients with kidney disease. It argues for the provision of supportive care by an interdisciplinary team led by nephrology clinicians to improve shared decision-making, advance care planning, pain and symptom management, the explicit offering of active medical management without dialysis as an option for patients who may not benefit from dialysis, and the removal by the Centers for Medicare & Medicaid Services and all other payors of financial and regulatory disincentives to quality supportive care, including hospice, for patients with or approaching kidney failure. It also emphasizes that all educational and accreditation programs for nephrology clinicians include kidney supportive care and its essential role in the care of patients with kidney disease.

Objective : Determine the prevalence of malnutrition per facility standards; examine interventions used to treat malnutrition; and share experiences, concerns, and solutions to problems in the management of malnutrition in dialysis patients in Texas. Design : Structured survey questionnaires. Setting : 196 outpatient hemodialysis (HD) and 86 peritoneal dialysis (PD) programs in End-Stage Renal Disease (ESRD) Network of Texas, Inc. Participants : Renal dietitians who worked in Texas dialysis facilities that treated chronic, outpatient adult, and pediatric ESRD patients on HD or PD. Measures : Criteria used to identify malnourished patients, prevalence of malnutrition in dialysis recipients, prevalence and types of interventions used to manage malnourished patients, and participation in quality management activities among renal dietitians. Results : For facilities that treated both HD and PD patients in 1996: (1) a significantly greater proportion of PD patients were identified as malnourished than HD patients: (2) facilities that had a high percentage of malnourished HD patients also had a high percentage of malnourished PD patients; (3) a significantly greater proportion of PD patients received commercial nutrition supplements than HD patients; and (4) use of tube feedings, intradialytic parenteral nutrition, intraperitoneal parenteral nutrition, and total parenteral nutrition among HD and PD patients decreased significantly from the past to the current survey year. Renal dietitians shared their experiences, concerns and solutions to problems in the management of malnutrition in this population. Conclusion : Results indicate a need to improve the nutritional status of malnourished dialysis patients, to increase consideration of tube feedings as viable nutrient delivery routes, and to maximize involvement of renal dietitians in the quality management process. With the cooperative effort of staff, care givers, patients, and family, early identification and appropriate interventions may improve the nutritional status and quality of life of dialysis patients.

Dialysis personnel are responsible for ensuring that patients’ rights and physical safety are protected in dialysis centers. Treatment of patients with cognitive impairment, including patients with dementia, presents special challenges. These patients may attempt to pull out their dialysis needles during treatment, potentially endangering themselves, dialysis center personnel, and other patients. Such patients may also compromise the care of other patients in the center by upsetting them and requiring a disproportionate amount of staff attention during treatment. Dialysis centers have learned to require families of such patients to provide a sitter to ensure that the patient remains safe during the dialysis treatment; however, some patients may exhibit unsafe behaviors despite a sitter, and not all families are willing to provide a sitter. In some instances, family members respond to the stress of a loved one who is unsafe on dialysis by being verbally or physically abusive to dialysis staff. This article presents a case in which the family member was a police officer who was not only verbally and physically intimidating to the staff but also insisted on bringing his police service weapon into the dialysis center. It describes the psychosocial, ethical, and legal responses to a family member who is disrupting what should be a calm environment in the dialysis center and recommends that dialysis centers proactively develop policies concerning safety for patients, family members, and other visitors that make no exceptions. The case also highlights the importance of adopting a no weapons policy and posting and enforcing a no weapons sign.

Hypoalbuminemia has been linked to an increased risk of mortality and morbidity in dialysis patients. The 1994 Health Care Financing Administration's Core Indicator Project reported that one in five adult hemodialysis patients had inadequate nutritional status as reflected by low serum albumin (SA) concentrations. In response to the need for education, intervention, and quality improvement tools, the ESRD Network No. 14 Medical Review Board formed a multidisciplinary task force to develop an algorithm for the team management of hypoalbuminemia. The Nutrition Subcommittee, representing renal dietitians from various practice settings across the state and dietitians from two metropolitan Council on Renal Nutrition chapters, was enlisted to provide professional validation. A systematic approach for overcoming barriers to adequate nutrient intake, which may improve low SA concentrations is outlined. The first step requires assurance of adequate dialysis. The second step focuses on assessment of nutrient intake, counseling, and education of the patient and significant others. The third step involves the coordinated efforts of the health care team in identifying, evaluating, and treating all concomitant conditions affecting the patient's nutritional status. More aggressive therapies, such as tube feeding, should be considered for willing candidates who cannot consume adequate protein and calories. The use of parenteral nutrition is reserved for patients with gastrointestinal dysfunction who do not respond to therapy administered via gastrointestinal routes. Each health care team member brings the strength of his or her unique perspective to the assessment and development of strategies. The multidisciplinary management approach, in partnership with the patient, enhances cooperation and problem solving to achieve desired outcomes.

■ Objective: To assess the frequency of use of intradialytic parenteral nutrition (IDPN) in hemodialysis (HD) facilities in Network No. 14 (TX) and to ascertain systems of IDPN practice in current use. ■ Data sources: 143 outpatient HD facilities in Texas, ESRD Network No. 14. ■ Data extraction: Professionally validated questionnaires were sent to all HD facilities in Texas in August 1992 to assess use of IDPN, patient selection criteria, infusion regimens, and monitoring and termination criteria. ■ Results: The frequency of use of IDPN varies widely, with a small percentage of facilities reporting 20% to 25% of the patient populations receiving this therapy. Twenty-seven percent of facilities are using essential amino acids in infusions. ■ Conclusions: Monitoring and termination criteria are often inconsistent and poorly defined. Long-term studies are needed to investigate optimal selection criteria, effect of various infusion regimens, and indices that best predict patient outcomes.