Advance Care Planning in Dialysis Patients: Is resuscitation always appropriate?
Abstract
Introduction:
Advance Care planning and discussions around resuscitation are important, especially when resuscitation is deemed inappropriate. Dialysis patients have a higher number of co-morbidities and poorer physiological reserve than an average patient. Therefore, it is important that advance care planning and resuscitation status is considered and documented appropriately in these patients.
Methods:
Haemodialysis patients aged >65 years who regularly attend a dialysis unit in Morriston Hospital were included. Using Vital Data, Medical notes and Welsh Clinical Portal, their Charlson Comorbidity Index, Clinical Frailty Score (CFS) and current resuscitation status was assessed. For those with a recorded “Do Not Attempt Cardiopulmonary Resuscitation” (DNACPR) order, presence of the order in their dialysis folder was evaluated. Such findings were then presented to the Renal Team to try and improve discussions and documentation around advance care planning and resuscitation.
Results:
48 patients were identified initially with 83% (n=40) having 2 or more co-morbidities. Levels of frailty between these patients varied with a median CFS of 5. 7 patients were later excluded in the post-intervention analysis due to moving dialysis units.
Pre-intervention, 27% (n=13) had an advance care plan documented which all consisted of a DNACPR. Only 38% (n=5) DNACPR orders were present in their dialysis packs.
Post-intervention, 41% (n=17) had an advance care plan documented with 86% (n=12) containing a DNACPR. 92% (n=11) of the DNACPR orders were present in their dialysis packs. Discussions around escalation in patients with a CFS > 5 relatively increased by 61.5% post intervention (Pre: CFS >5 = 35.3% (n=6/17) vs Post: CFS >5 = 57.0% (n=8/14).
Conclusion:
Discussions around advance care planning and resuscitation in frail, multi-comorbid dialysis patients are important. Educating clinicians on this topic has helped improve the discussion and documentations around advance care plans and DNACPR orders. This helps support clinicians in providing tailored, patient-centred care.