THE CESSATION OF DIALYSIS IN PATIENTS WITH END‐STAGE RENAL DISEASE: DEVELOPING AN APPROPRIATE EVIDENCE BASE FOR PRACTICE

Recently there has been a growing awareness that not all patients with Established Renal Failure will benefit from dialysis treatment, and it has been recognised that this patient population requires an enhanced approach to assessment and control of symptoms, as well as supportive management, including effective and high‐quality palliative care. This overview of the literature examines supportive care for the patient with Established Renal Failure and how conscious decision‐making in this group of patients can be best facilitated. It highlights recommendations, which have been produced to assist in the decision‐making process regarding withholding and withdrawing dialysis, and is a starting point prior to establishing supportive care programmes for the renal population. Patients who decide to abstain from dialysis or for whom such a decision is made should be offered appropriate supportive and palliative care.     

Options for prandial glucose management in type 2 diabetes patients using basal insulin: addition of a short‐acting GLP‐1 analogue versus progression to basal‐bolus therapy

Integrating patient‐centered diabetes care and algorithmic medicine poses particular challenges when optimized basal insulin fails to maintain glycaemic control in patients with type 2 diabetes. Multiple entwined physiological, psychosocial and systems barriers to insulin adherence are not easily studied and are not adequately considered in most treatment algorithms. Moreover, the limited number of alternatives to add‐on prandial insulin therapy has hindered shared decision‐making, a central feature of patient‐centered care. This article considers how the addition of a glucagon‐like peptide 1 (GLP‐1) analogue to basal insulin may provide new opportunities at this stage of treatment, especially for patients concerned about weight gain and risk of hypoglycaemia. A flexible framework for patient–clinician discussions is presented to encourage development of decision‐support tools applicable to both specialty and primary care practice.     

Emphysematous pyelonephritis in renal allograft related to antibody‐mediated rejection: A case report and literature review

Emphysematous pyelonephritis (EPN) is a rare condition which can rapidly progress to sepsis and multiple organ failure with high mortality. We experienced a rare case of EPN in a renal allograft related to antibody‐mediated rejection (AMR). The patient received a deceased donor kidney transplant due to end‐stage renal disease secondary to diabetes mellitus. Cross‐match test was negative but she had remote history of anti‐HLA‐A2 antibody corresponding with the donor HLA. Surgery concluded without any major events. Anti‐thymoglobulin was given perioperatively for induction. She was compliant with her immunosuppressive medications making urine of 2 L/d with serum creatinine of 1.9 mg/dL at discharge on post‐operative day (POD) 6. She did well until POD 14 when she presented to the clinic with features of sepsis, pain over the transplanted kidney area and decline in urine volume with elevated serum creatinine. CT revealed extensive gas throughout the transplanted kidney. Renal scan revealed non‐functional transplant kidney with no arterial flow. Based on these findings, a decision to perform transplant nephrectomy was made. At laparotomy, the kidney was completely necrotic. Pathology showed non‐viable kidney parenchyma with the tubules lacking neutrophilic casts suggestive of ischemic necrosis. Donor‐specific antibody (DSA) returned positive with high intensity anti‐HLA‐A2 antibody. This is the first case of early EPN in allograft considered to have occurred as a result of thrombotic ischemia secondary to AMR. This case suggests consideration of perioperative anti‐B‐cell and/or anti‐plasma cell therapies for historical DSA and strict post‐operative follow‐up in immunologically high‐risk recipients to detect early signs of rejection and avoid deleterious outcomes.     

Impediments to applying the ‘dignity of risk’ principle in residential aged care services

This discussion paper identifies four core factors currently impeding the application of the dignity of risk principle in residential aged care settings in Victoria, Australia: the fluctuating decision‐making ability of residents; multiple participants in decision‐making; discordance between espoused values and actions; and confusion and fear around legal responsibilities of care providers. Potential solutions identified include a conceptual shift in approach and consensus between key stakeholders, as well as more tangible solutions such as education and point‐of‐care decision support tools.     

Advance Care Planning in Cognitively Impaired Older Adults

Older adults with cognitive impairment face many healthcare challenges, chief among them participating in medical decision‐making about their own health care. Advance care planning (ACP) is the process whereby individuals communicate their wishes for future care with their clinicians and surrogate decision‐makers while they are still able to do so. ACP has been shown to improve important outcomes for individuals with cognitive impairment, but rates of ACP for these individuals are low because of individual‐, clinician‐, and system‐related factors. Addressing ACP early in the illness trajectory can maximize the chances that people can participate meaningfully. This article recommends best practices for approaching ACP for older adults with cognitive impairment. The importance of providing anticipatory guidance and eliciting values to guide future care to create a shared framework between clinicians, individuals, and surrogate decision‐makers is emphasized. It is recommended that ACP be approached as an iterative process to continue to honor and support people's wishes as cognitive impairment progresses and increasingly threatens independence and function. The article describes effective strategies for assessing decision‐making capacity, identifying surrogate decision‐makers, and using structured communication tools for ACP. It also provides guidelines for documentation and billing. Finally, special considerations for individuals with advanced dementia are described, including the use of artificial hydration and nutrition, decisions about site of care, and the role of hospice care.     

Ideal versus actual levels of decision‐making in South Australian aged care resident committees

Objective: To investigate the level and types of decision‐making residents have in lo‐level residential aged care facility (RACF) resident committees and whether this is in line with the level and types desired by the residents. Method: Fifteen South Australian low‐level RACFs participated in the study, with a total of 107 resident committee members completing questionnaires. Results: Residents wanted to participate significantly more in decision‐making than they currently were, particularly in the areas of deciding on new activities, planning menus and making policies on safety hazards. Conclusion: The existence of resident committees did not ensure that residents participated in decision‐making to the extent that they wished. Resident committees would benefit from regular evaluation to determine whether residents are provided with opportunities to participate in decision‐making in areas that are important to them and to the levels they desire.     

The decision‐making threshold and the factors that affect it: A qualitative study of patients' decision‐making in knee replacement surgery

Background

Osteoarthritis is a significant cause of burden to the ageing population and knee replacement is a common operation for treatment of end‐stage disease. We aimed to explore these factors to help understand patients' decision‐making, which is critical in informing patient‐centred care. These can be used to enhance decision‐making and dialogue between clinicians and patients, allowing a more informed choice.

Methods

The study consisted of two focus groups, in a patient cohort after total knee replacement followed by more in‐depth interviews to further test and explore themes from the focus groups, in patients in either the deliberation stage or the decision‐making stage.

Results

Using qualitative research methods (iterative thematic analysis) reviewing decision‐making and deliberation phases of making informed choices we found nine key themes that emerged from the study groups.

Conclusions

An awareness of the deliberation phase, the factors that influence it, the stress associated with it, preferred models of care, and the influence of the decision‐making threshold will aid useful communication between doctors and patients.     

DIALYSIS: PROLONGING LIFE OR PROLONGING DYING? ETHICAL,LEGAL AND PROFESSIONAL CONSIDERATIONS FOR END OF LIFE DECISION MAKING

There are over 7,000 people on dialysis in Australia and this is predicted to increase due to the ageing population and the high incidence of diabetes mellitus. Discontinuation of dialysis is the second most frequent cause of death in dialysis patients in Australia. Risk factors for the discontinuation of dialysis include: co‐morbidities (especially diabetes mellitus) and being older. Because the decision to discontinue dialysis is a major life choice, collaborative decision making should be encouraged, and the patient needs assurances of the continuation of care and kindness, a palliative care plan, and the alleviation of suffering. Patients decide to discontinue dialysis because of an unacceptable quality of life, depression and a chronic failure to thrive. Health professionals need to support end of life decision making using an ethical decision framework. A review of current literature was undertaken and revealed a paucity of information in regard to palliation in those with end stage renal disease who had discontinued dialysis. The fear of dying, pain, suffering, and abandonment that a patient and/or their family may perceive as being associated with death may create barriers to decisions to discontinue with dialysis treatments. Therefore health care personnel should provide information with honesty to allow patients to predict their quality of life and death. Support for the patient and family during the dying period should be multi‐disciplinary, with clear and timely communication between all members of the team.     

Fatal disseminated visceral varicella zoster virus infection in a renal transplant recipient

We report a case of fatal disseminated varicella zoster virus (VZV) with delayed–onset rash in a 66‐year‐old female more than 2 years following uncomplicated deceased donor renal transplantation. Whilst on a stable regimen of maintenance immunosuppression, the patient presented with chest and abdominal pain with concomitant hepatitis and pancreatitis. After pursuing multiple other potential causes of her symptoms, the correct diagnosis of VZV was only suspected after the development of a widespread vesicular rash—11 days after her initial symptoms. Despite antiviral therapy and inotropic support in the intensive care unit, the patient died. Simultaneous VZV hepatitis and pancreatitis in solid organ transplant recipients is uncommon. The new inactivated VZV vaccines have the potential to prevent post‐transplant infections, with promising early clinical data on safety and efficacy in renal transplant recipients. VZV is an important preventable infection that should be considered in immunocompromised patients, even in the absence of rash.     

Barriers to vaccination in renal transplant recipients

Vaccine‐preventable diseases remain at the forefront of challenges in the long‐term care of renal transplant recipients (RTR). Although global vaccination campaigns targeting patients with end‐stage renal disease or RTR are standard, rates of vaccination among renal transplant candidates and RTRs remain suboptimal. We highlight the multifactorial barriers leading to low vaccination rates in this vulnerable population.     

Evidence supporting the best clinical management of patients with multimorbidity and polypharmacy: a systematic guideline review and expert consensus

The complexity and heterogeneity of patients with multimorbidity and polypharmacy renders traditional disease‐oriented guidelines often inadequate and complicates clinical decision making. To address this challenge, guidelines have been developed on multimorbidity or polypharmacy. To systematically analyse their recommendations, we conducted a systematic guideline review using the Ariadne principles for managing multimorbidity as analytical framework. The information synthesis included a multistep consensus process involving 18 multidisciplinary experts from seven countries. We included eight guidelines (four each on multimorbidity and polypharmacy) and extracted about 250 recommendations. The guideline addressed (i) the identification of the target population (risk factors); (ii) the assessment of interacting conditions and treatments: medical history, clinical and psychosocial assessment including physiological status and frailty, reviews of medication and encounters with healthcare providers highlighting informational continuity; (iii) the need to incorporate patient preferences and goal setting: eliciting preferences and expectations, the process of shared decision making in relation to treatment options and the level of involvement of patients and carers; (iv) individualized management: guiding principles on optimization of treatment benefits over possible harms, treatment communication and the information content of medication/care plans; (v) monitoring and follow‐up: strategies in care planning, self‐management and medication‐related aspects, communication with patients including safety instructions and adherence, coordination of care regarding referral and discharge management, medication appropriateness and safety concerns. The spectrum of clinical and self‐management issues varied from guiding principles to specific recommendations and tools providing actionable support. The limited availability of reliable risk prediction models, feasible interventions of proven effectiveness and decision aids, and limited consensus on appropriate outcomes of care highlight major research deficits. An integrated approach to both multimorbidity and polypharmacy should be considered in future guidelines.     

A fourth dimension in decision making in hepatology

Today, the assessment of liver function in patients suffering from acute or chronic liver disease is based on liver biopsy and blood tests including synthetic function, liver enzymes and viral load, most of which provide only circumstantial evidence as to the degree of hepatic impairment. Most of these tests lack the degree of sensitivity to be useful for follow‐up of these patients at the frequency that is needed for decision making in clinical hepatology. Accurate assessment of liver function is essential to determine both short‐ and long‐term prognosis, and for making decisions about liver and non‐liver surgery, TIPS, chemoembolization or radiofrequency ablation in patients with chronic liver disease. Liver function tests can serve as the basis for accurate decision‐making regarding the need for liver transplantation in the setting of acute failure or in patients with chronic liver disease. The liver metabolic breath test relies on measuring exhaled ¹³C tagged methacetin, which is metabolized only by the liver. Measuring this liver‐specific substrate by means of molecular correlation spectroscopy is a rapid, non‐invasive method for assessing liver function at the point‐of‐care. The ¹³C methacetin breath test (MBT) is a powerful tool to aid clinical hepatologists in bedside decision‐making. Our recent findings regarding the ability of point‐of‐care ¹³C MBT to assess the hepatic functional reserve in patients with acute and chronic liver disease are reviewed along with suggested treatment algorithms for common liver disorders.     

The challenges of providing renal replacement therapy in decompensated liver cirrhosis

Development of renal failure requiring renal replacement therapy (RRT) in the cirrhotic patient is a devastating complication. Survival without RRT is less than 10% on average at 6 months. However, it is now appreciated that all renal failure in this group of patients is not due solely to hepatorenal syndrome, and the cause of the renal failure affects the prognosis. This paper reviews the prognosis depending on cause and points out the difficulty in making the correct diagnosis. Provision of RRT is difficult in this group of patients due to hypotension and coagulopathy which is highly prevalent. Survival with RRT is still poor with only 30-60% of patients surviving to liver transplant. Provision of RRT should be offered as a bridge to patients awaiting liver transplant or those undergoing liver transplant evaluation. Provision of long-term RRT is usually not indicated in other cirrhotic patients who develop a need for RRT except as a trial to see if renal function will return. The decision between intermittent hemodialysis or continuous renal replacement therapy (CRRT) is usually based on the clinical characteristics of the patient. Neither has been demonstrated to be superior to the other, although CRRT may be better tolerated in the unstable patient. CRRT is clearly indicated in cases of fulminant hepatic failure as it does not raise intracranial pressure. Provision of intraoperative CRRT during liver transplant may be indicated to help control volume and electrolytes in those patients presenting for liver transplant with renal failure. Newer extracorporeal support systems, such as extracorporeal albumin dialysis (MARS) and fractional plasma separation and adsorption with hemodialysis (Prometheus), have recently been developed to provide both renal and liver support in this group of patients. These are still considered experimental, although the MARS system has been utilized to treat patients with hepatorenal syndrome, and is available outside the United States.     

Physicians' Views on the Importance of Patient Preferences in Surrogate Decision‐Making

OBJECTIVES: To explore the degree to which physicians report reliance on patient preferences when making medical decisions for hospitalized patients lacking decisional capacity. DESIGN: Cross‐sectional survey. SETTING: One academic and two community hospitals in a single metropolitan area. PARTICIPANTS: Two hundred eighty‐one physicians who recently cared for hospitalized adults. MEASUREMENTS: A self‐administered survey addressing physicians' beliefs about ethical principles guiding surrogate decision‐making and physicians' recent decision‐making experiences. RESULTS: Overall, 72.6% of physicians identified a standard related to patient preferences as the most important ethical standard for surrogate decision‐making (61.2% identified advanced directives and 11.4% substituted judgment). Of the 73.3% of physicians who reported recently making a surrogate decision, 81.8% reported that patient preferences were highly important in decision‐making, although only 29.4% reported that patient preference was the most important factor in the decision. Physicians were significantly more likely to base decisions on patient preferences when the patient was in the intensive care unit (odds ratio (OR)=2.92, 95% confidence interval (CI)=1.15–7.45) and less likely when the patient was older (OR=0.76 for each decade of age, 95% CI=0.58–0.99). The presence of a living will, prior discussions with the patient, and the physicians' beliefs about ethical guidelines did not significantly predict the physicians' reliance on patient preferences. CONCLUSION: Although a majority of physicians identified patient preferences as the most important general ethical guideline for surrogate decision‐making, they relied on a variety of factors when making treatment decisions for a patient lacking decisional capacity.     

Caring for people who are dying on renal wards: a retrospective study

Unfortunately, there is still a high mortality rate among patients with end-stage renal disease (ESRD). If the decision is made to activate non-dialytic management of the patient with ESRD, it should be made jointly by the patient and responsible consultant nephrologist after consultation with relatives, the family doctor and other relevant members of the caring team. This paper discusses the establishment of a new renal supportive care service for patients opting not to have dialysis and focuses on the results of a 'death audit' carried out on this patient population. Recommendations for practice resulting from analysis of the audit results include, the use of advance directives, identification and prompt treatment of symptoms, increased staff education, timely referral to the palliative care team and expansion and further integration of the renal supportive care team.     

A patient centered approach to the treatment of renal vascular disease to prevent end stage renal failure

Atherosclerotic renal vascular disease (RVD) is a cause of renal failure especially in the elderly. There has never been a clinical trial to determine how effective invasive therapy is over medical therapy to prevent end stage renal disease. The objective of this study was to determine how effective invasive therapy for RVD to prevent renal failure should be from the perspective of the patient to warrant implementation. Subjects included 28 elderly dialysis patients and 26 renal health care workers (HCW). Subjects were asked directly how effective invasive therapy should be if they were to undertake the procedure. Invasive therapy would have to eliminate the need for dialysis permanently by 41 ± 6% for the dialysis patients and 21 ± 4% for the HCW to be acceptable. This difference in efficacy between the two groups was statistically significant (P = 0.014). Efficacy was also determined using a medical decision analysis model that incorporated patient health related quality of life status for dialysis and non-dialysis. To be cost-effective (<50,000 incremental cost/quality adjusted life year) invasive therapy had to reduce the development of end stage renal failure by 35 ± 1% (M ± SE) for dialysis patients and 15 ± 1% for HCW. These results show that patients demand better efficacy rates than their providers and that this difference appears to be appropriate based on their perceptions of health and projected outcomes. Both patient and health care workers are more conservative than predicted by the medical decision analysis model. Since the range of patient responses was large, methods of documenting patient perspectives for risky procedures may help clinicians determine how aggressively to investigate and treat patients with RVD.     

Expanding Therapeutic Options for Older Adults: Case‐Based Updates in Breast and Lung Cancer

Oncology care has become increasingly complex, with a dramatic increase in the number of available therapy options. Many newly developed medications have novel mechanisms of action and include targeted therapies and immunotherapy options. These agents typically have unique side effects that differ from more traditional cytotoxic chemotherapy regimens. Older adults represent the majority of patients with cancer and it is important for geriatricians and primary care providers for older adults to have a general understanding of newer agents and novel therapies, in order to aid in decision‐making and supportive care strategies during oncology treatment. This review provides a case‐based approach to discussing emerging therapeutic treatment options, including targeted therapies and immune‐based therapies, in two common malignancies affecting older adults. Incorporation of available evidence of specific novel therapies in older adult populations is discussed. J Am Geriatr Soc 67:1012–1019, 2019.     

Informing clinical practice guideline development and implementation: prevalence of coexisting conditions among adults with coronary heart disease

OBJECTIVES: To describe the prevalence of coexisting conditions that affect clinical decision‐making in adults with coronary heart disease (CHD). DESIGN: Cross‐sectional. SETTING: National Health and Nutrition Examination Survey, 1999 to 2004. PARTICIPANTS: Eight thousand six hundred fifty‐four people aged 45 and older; 1,259 with CHD. MEASUREMENTS: Coexisting conditions relevant to clinical decision‐making and implementing therapy for CHD across three domains: chronic diseases, self‐reported and laboratory‐based clinical measures, and health status factors of self‐reported and observed function. Prevalence was estimated according to sex and age, mutually exclusive patterns were examined, and the odds ratios (OR) of having incurred repeated hospitalization in the last year of participants with CHD and each complexity pattern versus CHD alone were modeled. RESULTS: The prevalence of comorbid chronic diseases in subjects with CHD was 56.7% for arthritis, 29.0% for congestive heart failure, 25.5% for chronic lower respiratory tract disease, 24.8% for diabetes mellitus, and 13.8% for stroke. Clinical factors adding to complexity of clinical decision‐making for CHD were use of more than four medications (54.5%), urinary incontinence (48.6%), dizziness or falls (34.8%), low glomerular filtration rate (24.4%), anemia (10.1%), high alanine aminotransferase (5.9%), use of warfarin (10.2%), and health status factors were cognitive impairment (29.9%), mobility difficulty (40.4%), frequent mental distress (14.3%), visual impairment (16.7%), and hearing impairment (17.9%). Several comorbidity patterns were associated with high odds of hospitalization. CONCLUSION: Coexisting conditions that may modify the effectiveness of or interact with CHD therapies, influence the feasibility of CHD therapies, or alter patients' priorities concerning their health care should be considered in the development of trials and guidelines to better inform real‐world clinical decision‐making.     

Artificial intelligence in pancreaticobiliary endoscopy

Artificial intelligence (AI) applications in health care have exponentially increased in recent years, and a few of these are related to pancreatobiliary disorders. AI‐based methods were applied to extract information, in prognostication, to guide clinical treatment decisions and in pancreatobiliary endoscopy to characterize lesions. AI applications in endoscopy are expected to reduce inter‐operator variability, improve the accuracy of diagnosis, and assist in therapeutic decision‐making in real time. AI‐based literature must however be interpreted with caution given the limited external validation. A multidisciplinary approach combining clinical and imaging or endoscopy data will better utilize AI‐based technologies to further improve patient care.