Advertisement
American Journal of Kidney Diseases

Advance Care Planning for Adults With CKD: A Systematic Integrative Review

Published:January 16, 2014DOI:https://doi.org/10.1053/j.ajkd.2013.12.007

      Background

      Recent clinical practice guidelines have highlighted the importance of advance care planning (ACP) for improving end-of-life care for people with chronic kidney disease (CKD).

      Study Design

      We conducted a systematic integrative review of the literature to inform future ACP practice and research in CKD, searching electronic databases in April 2013. Synthesis used narrative methods.

      Setting & Population

      We focused on adults with a primary diagnosis of CKD in any setting.

      Selection Criteria for Studies

      We included studies of any design, quantitative or qualitative.

      Interventions

      ACP was defined as any formal means taken to ensure that health professionals and family members are aware of patients’ wishes for care in the event they become too unwell to speak for themselves.

      Outcomes

      Measures of all kinds were considered of interest.

      Results

      55 articles met criteria reporting on 51 discrete samples. All patient samples included people with CKD stage 5; 2 also included patients with stage 4. Seven interventions were tested; all were narrowly focused and none was evaluated by comparing wishes for end-of-life care with care received. One intervention demonstrated effects on patient and family outcomes in the form of improved well-being and anxiety following sessions with a peer mentor. Insights from qualitative studies that have not been used to inform interventions include the importance of instilling patient confidence that their advance directives will be enacted and discussing decisions about (dis)continuing dialysis therapy separately from “aggressive” life-sustaining treatments (eg, ventilation).

      Limitations

      Although quantitative and qualitative findings were integrated according to best practice, methods for this are in their infancy.

      Conclusions

      Research on ACP in patients with CKD is limited, especially intervention studies. Interventions in CKD should attend to barriers and facilitators at the levels of patient, caregiver, health professional, and system. Intervention studies should measure impact on compliance with patient wishes for end-of-life care.

      Index Words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to American Journal of Kidney Diseases
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Kjellstrand C.M.
        • Blagg C.R.
        Differences in dialysis practice are the main reasons for the high mortality rate in the United States compared to Japan.
        Hemodialysis. 2003; 7: 67-71
        • Dasgupta I.
        • Rayner H.C.
        In good conscience—safely withholding dialysis in the elderly.
        Semin Dial. 2009; 22: 476-479
      1. Chambers E.J. Brown E.A. Germain M.J. Supportive Care for the Renal Patient. 2nd ed. Oxford University Press, Oxford2010
        • Khatri M.
        • Nickolas T.
        • Moon Y.P.
        • et al.
        CKD associates with cognitive decline.
        J Am Soc Nephrol. 2009; 20: 2427-2432
        • Murray A.M.
        • Tupper D.E.
        • Knopman D.S.
        • et al.
        Cognitive impairment in haemodialysis patients is common.
        Neurology. 2006; 67: 216-223
        • Shalowitz D.I.
        • Garrett-Mayer E.
        • Wendler D.
        The accuracy of surrogate decision makers: a systematic review.
        Arch Intern Med. 2006; 166: 493-497
        • Davison S.N.
        Advance care planning in patients with end-stage renal disease.
        Prog Palliat Care. 2009; 17: 170-178
        • Davison S.N.
        Integrating palliative care for patients with advanced chronic kidney disease: recent advances, remaining challenges.
        J Palliat Care. 2011; 27: 53-61
        • Davison S.N.
        • Torgunrud C.
        The creation of an advance care planning process for patients with ESRD.
        Am J Kidney Dis. 2007; 49: 27-36
        • Detering K.M.
        • Hancock A.D.
        • Reade M.C.
        • Silvester W.
        The impact of advance care planning on end of life care in elderly patients: randomised controlled trial.
        BMJ. 2010; 340: c1345
        • Molloy D.W.
        • Guyatt G.H.
        • Russo R.
        • et al.
        Systematic implementation of an advance directive program in nursing homes: a randomized controlled trial.
        JAMA. 2000; 283: 1437-1444
        • Hammes B.J.
        • Rooney B.L.
        Death and end-of-life planning in one midwestern community.
        Arch Intern Med. 1998; 158: 383-390
        • Silveira M.J.
        • Kim S.Y.
        • Langa K.M.
        Advance directives and outcomes of surrogate decision making before death.
        N Engl J Med. 2010; 362: 1211-1218
        • Wright A.A.
        • Zhang B.
        • Ray A.
        • et al.
        Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment.
        JAMA. 2008; 300: 1665-1673
        • Teno J.M.
        • Gruneir A.
        • Schwartz Z.
        • et al.
        Association between advance directives and quality of end-of-life care: a national study.
        J Am Geriatr Soc. 2007; 55: 189-194
        • Hickman S.E.
        • Nelson C.A.
        • Moss A.H.
        • Tolle S.W.
        • Perrin N.A.
        • Hammes B.J.
        The consistency between treatments provided to nursing facility residents and orders on the physician orders for life-sustaining treatment form.
        J Am Geriatr Soc. 2011; 59: 2091-2099
        • Monturo C.A.
        • Strumpf N.E.
        Advance directives at end-of-life: nursing home resident preferences for artificial nutrition.
        J Am Med Dir Assoc. 2007; 8: 224-228
        • Noble H.
        • Meyer J.
        • Bridges J.
        • Kelly D.
        • Johnson B.
        Patient experience of dialysis refusal or withdrawal—a review of the literature.
        J Ren Care. 2008; 34: 94-100
        • Holley J.L.
        Advance care planning in elderly chronic dialysis patients.
        Int Urol Nephrol. 2003; 35: 565-568
        • Holley J.L.
        Palliative care in end-stage renal disease: focus on advance care planning, hospice referral, and bereavement.
        Semin Dial. 2005; 18: 154-156
        • Loftin L.P.
        • Beumer C.
        Collaborative end-of-life decision making in end stage renal disease.
        ANNA J. 1998; 25: 615-617
        • Mendelssohn D.C.
        • Singer P.A.
        Advance directives in dialysis.
        Adv Ren Replace Ther. 1994; 1: 240-250
        • Bartlow B.
        In search of an advance directive that works for end-stage renal disease patients.
        Hemodialysis. 2006; 10: S38-S45
        • Davison S.N.
        Advance care planning in patients with end stage renal disease.
        Prog Palliat Care. 2009; 17: 170-178
        • Renal Physicians Association
        Shared Decision Making in the Appropriate Initiation of and Withdrawal From Dialysis: Clinical Practice Guideline.
        RPA, Rockville, MD2010
        • Brown M.A.
        • Crail S.M.
        • Masterson R.
        • et al.
        ANZSN Renal Supportive Care Guidelines 2013.
        Nephrology. 2013; 18: 401-454
        • Whittemore R.
        • Knafl K.
        The integrative review: updated methodology.
        J Adv Nurs. 2005; 52: 546-553
        • Denzin N.K.
        • Lincoln Y.S.
        Introduction. Entering the field of qualitative research.
        in: Denzin N.K. Lincoln Y.S. Handbook of Qualitative Research. Sage Publications, Thousand Oaks, CA1994: 1-17
        • Morrison A.
        • Polisena J.
        • Husereau D.
        • et al.
        The effect of English-language restriction on systematic review-based meta-analyses: a systematic review of empirical studies.
        Int J Technol Assess Health Care. 2012; 28: 138-144
        • Breckenridge D.M.
        Decisions regarding dialysis treatment modality: a holistic perspective.
        Holist Nurs Pract. 1997; 12: 54-61
      2. Agency for Healthcare Research and Quality. US Preventive Services Task Force Procedure Manual. 2008. http://www.uspreventiveservicestaskforce.org/uspstf08/methods/procmanual.pdf. Accessed April 12, 2013.

        • Popay J.
        • Roberts H.
        • Sowden A.
        • et al.
        Guidance on the Conduct of Narrative Synthesis in Systematic Reviews: Final Report. A Product From the ESRC Methods Programme.
        University of Lancaster, Lancaster, UK2006
        • Arai L.
        • Britten N.
        • Popay J.
        • et al.
        Testing methodological developments in the conduct of narrative synthesis: a demonstration review of research on the implementation of smoke alarm interventions.
        Evid Policy. 2007; 3: 361-383
        • Rodgers M.
        • Petticrew M.
        • Sowden A.
        • et al.
        Testing methodological guidance on the conduct of narrative synthesis in systematic reviews: effectiveness of interventions to promote smoke alarm ownership and function.
        Evaluation. 2009; 15: 49-73
      3. Deeks JJ, Higgins JPT, Altman DG. Chapter 9: Analysing data and undertaking meta-analyses. In: Higgins JPT, Green S, eds. The Cochrane Collaboration. Cochrane Handbook for Systematic Reviews of Interventions Version 5.0.1 [updated September 2008]. The Cochrane Collaboration, 2008. Available at: www.cochrane-handbook.org.

        • Thomas J.
        • Harden A.
        • Oakley A.
        • et al.
        Integrating qualitative research with trials in systematic reviews.
        BMJ. 2004; 328: 1010-1012
      4. Noyes J, Popay J, Pearson A, Hannes K, Booth A; on behalf of the Cochrane Qualitative Research Methods Group. Chapter 20: Qualitative research and Cochrane reviews. In: Higgins JPT, Green S, eds. The Cochrane Collaboration. Cochrane Handbook for Systematic Reviews of Interventions Version 5.0.1 [updated September 2008]. The Cochrane Collaboration, 2008. Available at: www.cochrane-handbook.org.

        • Anderson J.E.
        • Sikorski I.
        • Finucane T.E.
        Advance care planning by or on behalf of peritoneal dialysis patients in long-term care.
        Am J Kidney Dis. 2006; 48: 122-127
        • Baharoon S.A.
        • Al-Jahdali H.H.
        • Al-Sayyari A.A.
        • Tamim H.
        • Babgi Y.
        • Al-Ghamdi S.M.
        Factors associated with decision-making about end-of-life care by hemodialysis patients.
        Saudi J Kidney Dis Transpl. 2010; 21: 447-453
        • Berzoff J.
        • Swantkowski J.
        • Cohen L.M.
        Developing a renal supportive care team from the voices of patients, families, and palliative care staff.
        Palliat Support Care. 2008; 6: 133-139
        • Calvin A.O.
        Haemodialysis patients and end-of-life decisions: a theory of personal preservation.
        J Adv Nurs. 2004; 46: 558-566
        • Calvin A.O.
        • Eriksen L.R.
        Assessing advance care planning readiness in individuals with kidney failure [corrected].
        Nephrol Nurs J. 2006; 33 ([published erratum appears in Nephrol Nurs J. 2006;33(4):380]): 165-171
        • Cohen L.M.
        • Germain M.
        • Woods A.
        • et al.
        Patient attitudes and psychological considerations in dialysis discontinuation.
        Psychosomatics. 1993; 34: 395-401
        • Cohen L.M.
        • McCue J.D.
        • Germain M.
        • Woods A.
        Denying the dying: advance directives and dialysis discontinuation.
        Psychosomatics. 1997; 38: 27-34
        • Davison S.N.
        Facilitating advance care planning for patients with end-stage renal disease: the patient perspective.
        Clin J Am Soc Nephrol. 2006; 1: 1023-1028
        • Davison S.N.
        End-of-life care preferences and needs: perceptions of patients with chronic kidney disease.
        Clin J Am Soc Nephrol. 2010; 5: 195-204
        • Davison S.N.
        • Kromm S.K.
        • Currie G.R.
        Patient and health professional preferences for organ allocation and procurement, end-of-life care and organization of care for patients with chronic kidney disease using a discrete choice experiment.
        Nephrol Dial Transplant. 2010; 25: 2334-2341
        • Davison S.N.
        • Simpson C.
        Hope and advance care planning in patients with end stage renal disease: qualitative interview study.
        BMJ. 2006; 333: 886
        • Hines S.C.
        • Glover J.J.
        • Babrow A.S.
        • Holley J.L.
        • Badzek L.A.
        • Moss A.H.
        Improving advance care planning by accommodating family preferences.
        J Palliat Med. 2001; 4: 481-489
        • Holley J.L.
        • Hines S.C.
        • Glover J.J.
        • Babrow A.S.
        • Badzek L.A.
        • Moss A.H.
        Failure of advance care planning to elicit patients' preferences for withdrawal from dialysis.
        Am J Kidney Dis. 1999; 33: 688-693
        • Holley J.L.
        • Nespor S.
        • Rault R.
        The effects of providing chronic hemodialysis patients written material on advance directives.
        Am J Kidney Dis. 1993; 22: 413-418
        • Holley J.L.
        • Nespor S.
        • Rault R.
        Chronic in-center hemodialysis patients' attitudes, knowledge, and behavior towards advance directives.
        J Am Soc Nephrol. 1993; 3: 1405-1408
        • Holley J.L.
        • Stackiewicz L.
        • Dacko C.
        • Rault R.
        Factors influencing dialysis patients' completion of advance directives.
        Am J Kidney Dis. 1997; 30: 356-360
        • Hopkins D.J.
        • Kott M.R.
        • Pirozzi J.
        • et al.
        End-of-life issues and the patient with renal disease: an evidence-based practice project.
        Nephrol Nurs J. 2011; 38: 79-83
        • Kataoka-Yahiro M.R.
        • Yancura L.A.
        • Page V.
        • Inouye J.
        Advance care planning decision making among Asian Pacific Islander family caregivers of stage 4 to 5 chronic kidney disease patients on hemodialysis: a focus group study.
        J Hospice Palliat Nurs. 2011; 13: 426-435
        • Lemay Jr., E.P.
        • Pruchno R.A.
        • Feild L.
        Accuracy and bias in perceptions of spouses' life-sustaining medical treatment preferences.
        J Appl Soc Psychol. 2006; 36: 2337-2361
        • McKeown A.
        • Agar R.
        • Gambles M.
        • Ellershaw J.E.
        • Hugel H.
        Renal failure and specialist palliative care: an assessment of current referral practice.
        Int J Palliat Nurs. 2008; 14: 454-458
        • Noble H.
        • Rees K.
        Caring for people who are dying on renal wards: a retrospective study.
        EDTNA ERCA J. 2006; 32: 89-92
        • Perry E.
        • Buck C.
        • Newsome J.
        • Berger C.
        • Messana J.
        • Swartz R.
        Dialysis staff influence patients in formulating their advance directives.
        Am J Kidney Dis. 1995; 25: 262-268
        • Perry E.
        • Swartz J.
        • Brown S.
        • Smith D.
        • Kelly G.
        • Swartz R.
        Peer mentoring: a culturally sensitive approach to end-of-life planning for long-term dialysis patients.
        Am J Kidney Dis. 2005; 46: 111-119
        • Perry E.
        • Swartz R.
        • Smith-Wheelock L.
        • Westbrook J.
        • Buck C.
        Why is it difficult for staff to discuss advance directives with chronic dialysis patients?.
        J Am Soc Nephrol. 1996; 7: 2160-2168
        • Perry L.D.
        • Nicholas D.
        • Molzahn A.E.
        • Dossetor J.B.
        Attitudes of dialysis patients and caregivers regarding advance directives.
        ANNA J. 1995; 22: 457
        • Pruchno R.
        • Cartwright F.P.
        • Wilson-Genderson M.
        The effects of race on patient preferences and spouse substituted judgments.
        Int J Aging Hum Dev. 2009; 69: 31-54
        • Pruchno R.A.
        • Lemay Jr., E.P.
        • Feild L.
        • Levinsky N.G.
        Predictors of patient treatment preferences and spouse substituted judgments: the case of dialysis continuation.
        Med Decis Making. 2006; 26: 112-121
        • Quintana B.J.
        • Nevarez M.
        • Rogers K.
        • Murata G.H.
        • Tzamaloukas A.H.
        Reaction of patients on chronic dialysis to discussions about cardiopulmonary resuscitation.
        ANNA J. 1991; 18: 29-32
        • Rutecki G.W.
        • Rodriguez L.
        • Cugino A.
        • Jarjoura D.
        • Hastings F.
        • Whittier F.C.
        End of life issues in ESRD. A study of three decision variables that affect patient attitudes.
        ASAIO J. 1994; 40: M798-M802
        • Saltbaek L.
        • Tvedegaard E.
        Decision to resuscitate or not in patients with chronic diseases [abstract].
        Dan Med J. 2012; 59: A4353
        • Sanchez-Tomero J.A.
        • Rodriguez-Jornet A.
        • Balda S.
        • et al.
        Exploring the opinion of CKD patients on dialysis regarding end-of-life and advance care planning.
        Nefrologia. 2011; 31: 449-456
        • Sehgal A.
        • Galbraith A.
        • Chesney M.
        • Schoenfeld P.
        • Charles G.
        • Lo B.
        How strictly do dialysis patients want their advance directives followed?.
        JAMA. 1992; 267: 59-63
        • Sehgal A.R.
        • Weisheit C.
        • Miura Y.
        • Butzlaff M.
        • Kielstein R.
        • Taguchi Y.
        Advance directives and withdrawal of dialysis in the United States, Germany, and Japan.
        JAMA. 1996; 276: 1652-1656
        • Sekkarie M.A.
        • Moss A.H.
        Withholding and withdrawing dialysis: the role of physician specialty and education and patient functional status.
        Am J Kidney Dis. 1998; 31: 464-472
        • Simon J.
        • Murray A.
        • Raffin S.
        Facilitated advance care planning: what is the patient experience?.
        J Palliat Care. 2008; 24: 256-264
        • Song M.-K.
        • Donovan H.S.
        • Piraino B.M.
        • et al.
        Effects of an intervention to improve communication about end-of-life care among African Americans with chronic kidney disease.
        Appl Nurs Res. 2010; 23: 65-72
        • Song M.-K.
        • Hanson L.C.
        Relationships between psychosocial-spiritual well-being and end-of-life preferences and values in African American dialysis patients.
        J Pain Sympt Manag. 2009; 38: 372-380
        • Song M.-K.
        • Ward S.E.
        • Happ M.B.
        • et al.
        Randomized controlled trial of SPIRIT: an effective approach to preparing African-American dialysis patients and families for end of life.
        Res Nurs Health. 2009; 32: 260-273
        • Swartz R.D.
        • Perry E.
        Advance directives are associated with “good deaths” in chronic dialysis patients.
        J Am Soc Nephrol. 1993; 3: 1623-1630
        • Tigert J.
        • Chaloner N.
        • Scarr B.
        • Webster K.
        Development of a pamphlet: introducing advance directives to hemodialysis patients and their families.
        CANNT J. 2005; 15: 20-24
        • Yee A.
        • Seow Y.Y.
        • Tan S.H.
        • Goh C.
        • Qu L.
        • Lee G.
        What do renal health-care professionals in Singapore think of advance care planning for patients with end-stage renal disease?.
        Nephrology. 2011; 16: 232-238
        • Al-Jahdali H.H.
        • Bahroon S.
        • Babgi Y.
        • Tamim H.
        • Al-Ghamdi S.M.
        • Al-Sayyari A.A.
        Advance care planning preferences among dialysis patients and factors influencing their decisions.
        Saudi J Kidney Dis Transpl. 2009; 20: 232-239
        • Fissell R.B.
        • Bragg-Gresham J.L.
        • Lopes A.A.
        • et al.
        Factors associated with “do not resuscitate” orders and rates of withdrawal from hemodialysis in the international DOPPS.
        Kidney Int. 2005; 68: 1282-1288
        • Hines S.C.
        • Glover J.
        • Holley J.
        • Babrow A.
        • Badzek L.
        • Moss A.
        Dialysis patients’ preferences for family-based advance care planning.
        Ann Intern Med. 1999; 130: 825-828
        • Holley J.L.
        • Finucane T.E.
        • Moss A.H.
        Dialysis patients' attitudes about cardiopulmonary resuscitation and stopping dialysis.
        Am J Nephrol. 1989; 9: 245-251
        • Miura Y.
        • Asai A.
        • Matsushima M.
        • et al.
        Families' and physicians' predictions of dialysis patients' preferences regarding life-sustaining treatments in Japan.
        Am J Kidney Dis. 2006; 47: 122-130
        • Miura Y.
        • Asai A.
        • Nagata S.
        • et al.
        Dialysis patients' preferences regarding cardiopulmonary resuscitation and withdrawal of dialysis in Japan.
        Am J Kidney Dis. 2001; 37: 1216-1222
        • Moss A.H.
        • Hozayen O.
        • King K.
        • Holley J.L.
        • Schmidt R.J.
        Attitudes of patients toward cardiopulmonary resuscitation in the dialysis unit.
        Am J Kidney Dis. 2001; 38: 847-852
        • Ostermann M.E.
        • Nelson S.R.
        Haemodialysis patients' views on their resuscitation status.
        Nephrol Dial Transplant. 2003; 18: 1644-1647
        • Reilly G.S.
        A questionnaire for dialysis patients on treatment cessation issues.
        Dial Transplant. 1990; 19: 533-545
        • Rogers K.
        • Crawford D.
        • Tzamaloukas A.
        Cardiopulmonary resuscitation preferences of patients on chronic hemodialysis.
        Dial Transplant. 1990; 19: 182-184
        • Singer P.A.
        • Thiel E.C.
        • Naylor C.D.
        • et al.
        Life-sustaining treatment preferences of hemodialysis patients: implications for advance directives.
        J Am Soc Nephrol. 1995; 6: 1410-1417
        • Song M.-K.
        • Ward S.E.
        • Lin F.-C.
        End-of-life decision-making confidence in surrogates of African-American dialysis patients is overly optimistic.
        J Palliat Med. 2012; 15: 412-417
        • Tamura M.K.
        • Goldstein M.K.
        • Perez-Stable E.J.
        Preferences for dialysis withdrawal and engagement in advance care planning within a diverse sample of dialysis patients.
        Nephrol Dial Transplant. 2010; 25: 237-242
        • Weisbord S.
        • Carmody S.
        • Bruns F.
        • et al.
        Symptom burden, quality of life, advance care planning and the potential value of palliative care in severely ill haemodialysis patients.
        Nephrol Dial Transplant. 2003; 18: 1345-1352
        • Collins M.
        • Lehane E.
        Perspectives on death, dying and advance care planning from patients receiving haemodialysis.
        J Ren Care. 2013; 39: 5-11
        • Donovan H.S.
        • Ward S.
        A representational approach to patient education.
        J Nurs Scholarsh. 2001; 33: 211-216
        • Kirchhoff K.T.
        • Hammes B.J.
        • Kehl K.A.
        • Briggs L.A.
        • Brown R.L.
        Effect of a disease-specific planning intervention on surrogate understanding of patient goals for future medical treatment.
        J Am Geriatr Soc. 2010; 58: 1233-1240
        • Kirchhoff K.T.
        • Hammes B.J.
        • Kehl K.A.
        • Briggs L.A.
        • Brown R.L.
        Effect of a disease-specific advance care planning intervention on end-of-life care.
        J Am Geriatr Soc. 2012; 60: 946-950
        • Craig P.
        • Dieppe P.
        • Macintyre S.
        • et al.
        Developing and evaluating complex interventions: the new Medical Research Council guidance [abstract].
        BMJ. 2008; 337: a1655
        • Dobbins E.H.
        End-of-life decisions: influence of advance directives on patient care.
        J Gerontol Nurs. 2007; 33: 50-56
        • Hirschman K.B.
        • Kapo J.
        • Karlawish J.
        Why doesn't a family member of a person with advanced dementia use a substituted judgment when making a decision for that person?.
        Am J Geriatr Psychiatry. 2006; 14: 659-667
        • Hopp F.P.
        • Duffy S.A.
        Racial variations in end-of-life care.
        J Am Geriatr Soc. 2000; 48: 658-663
        • Noble H.
        Supportive and palliative care for the patient with end-stage renal disease.
        Br J Nurs. 2008; 17: 498-504
      5. Kidney End-of-Life Coalition. Choosing not to start and choosing to stop dialysis. 2008. http://www.kidneyeol.org/Advance-Care-Planning/For-Patients/Starting-Stopping-Dialysis.aspx. Accessed November 6, 2012.

        • Schell J.O.
        • Patel U.D.
        • Steinhauser K.E.
        • Ammarell N.
        • Tulsky J.A.
        Discussions of the kidney disease trajectory by elderly patients and nephrologists: a qualitative study.
        Am J Kidney Dis. 2012; 59: 495-503
        • Wachterman M.W.
        • Marcantonio E.R.
        • Davis R.B.
        • et al.
        Relationship between the prognostic expectations of seriously ill patients undergoing hemodialysis and their nephrologists.
        JAMA Intern Med. 2013; 173: 1206-1214
        • Michie S.
        • Fixsen D.
        • Grimshaw J.M.
        • Eccles M.P.
        Specifying and reporting complex behaviour change interventions: the need for a scientific method.
        Implement Sci. 2009; 4: 40

      Linked Article

      • Decisions About Dialysis and Other Life-Sustaining Treatments Should Not Be Made Separately
        American Journal of Kidney DiseasesVol. 64Issue 5
        • Preview
          In a review of advance care planning (ACP) interventions for adults with chronic kidney disease, Luckett et al1 report that qualitative studies they examined recommend that “decisions about continuing dialysis should not be grouped with those regarding aggressive life-sustaining treatments (eg, CPR [cardiopulmonary resusitation], ventilation) [because] patients may perceive these intervention types very differently.”1(p766) We argue that the decision to withdraw from dialysis therapy should not be made separately from decisions regarding other life-sustaining treatments; rather, the dialysis decision should be a clear, explicit component of end-of-life discussions.
        • Full-Text
        • PDF