Nephrologist-Facilitated Advance Care Planning for Hemodialysis Patients: A Quality Improvement Project

Background The Renal Physicians Association's clinical practice guideline recommends that physicians address advance care planning with dialysis patients. However, data are lacking about how best to implement this recommendation. Study Design Quality improvement project. Settings & Participants Nephrologists caring for patients treated with maintenance hemodialysis at 2 dialysis facilities identified patients who might benefit most from advance care planning using the “surprise” question (“Would I be surprised if this patient died in the next year?”). Quality Improvement Plan Patients identified with a “no” response to the surprise question were invited to participate in nephrologist-facilitated advance care planning, including completion of a Medical Orders for Life-Sustaining Treatment (MOLST) form. Outcomes Change in MOLST completion rate and identification of preferences for limits on life-sustaining treatment. Measurements Pre- and postintervention code status, MOLST completion rate, and vital status at 1 year. Results Nephrologists answered “no” to the surprise question for 50 of 201 (25%) hemodialysis patients. Of these, 41 (82%) patients had a full-code status and 9 (18%) had a do-not-resuscitate (DNR) status. Encounters lasted 15 to 60 minutes. Following the encounter, 21 (42%) patients expressed preference for a DNR status and 29 (58%) maintained full-code status ( P = 0.001). The MOLST completion rate increased from 10% to 90%. One-year survival for patients whose nephrologists answered “no” to the surprise question was 58% compared to 92% for those with a “yes” answer ( P < 0.001). Limitations Sample size and possible nonrepresentative dialysis population. Conclusions Nephrologist-facilitated advance care planning targeting hemodialysis patients with limited life expectancy led to significant changes in documented patient preferences for cardiopulmonary resuscitation and limits on life-sustaining treatment. These changes demonstrate the benefit of advance care planning with dialysis patients and likely reflect better understanding of end-of-life treatment options.