Assessing Perceptions of Positive and Negative Content within Goals of Care Notes.

Context: Clinician documentation of negative content in electronic health record notes is known to exist.

Objectives: To assess community members and clinicians perceptions about negative content within goals of care conversation (GOCC) notes.

Methods: We conducted a mixed-methods study of community member and clinician perspectives about positive, neutral and negative content within GOCC notes written by clinicians across 14 hospitals.

Patient Perceptions of a Population Health Management Program to Improve Kidney Care: Optimizing care in CKD.

Rationale & Objective: A population health management intervention for a pragmatic cluster randomized control trial (Kidney CHAMP) aimed to improve care and outcomes in patients with chronic kidney disease (CKD) at high-risk of progression to dialysis dependence but not seeing a nephrologist. The Kidney CHAMP intervention provided comanagement support to primary care providers by nephrology electronic-consult, pharmacist-directed medication reconciliation, and nurse-delivered CKD patient education. We sought to learn patient perceptions of Kidney CHAMP intervention and whether the intervention improved their understanding of CKD.

Assessing the Content of Goals of Care Documentation for Hospitalized Patients With Alzheimer's Disease and Related Dementias.

Background: Goals of care (GOC) conversations are an evidence-based practice that help clarify and align patient values and preferences for medical care with treatment options. Little is known about how clinicians document the content of GOC conversations for patients with Alzheimer's disease and related dementias (AD/ADRD) in the electronic health record (EHR) and whether this may differ across hospitals. We aimed to assess the content of GOC documentation for hospitalized patients with and without AD/ADRD.

Characterizing the Documentation of Time-Limited Trials in Goals of Care Notes.

Context: Time-limited trials (TLTs) are a collaborative plan among clinicians, patients, and surrogates to use life-sustaining therapy for a defined duration, after which the response to therapy informs the decision to either continue care focused on recovery or transition to comfort-focused care.

Objectives: To evaluate 1) how often goals of care (GOC) notes document TLT use; 2) what patient and clinician characteristics are associated with documented TLTs; and 3) how TLTs are described in GOC documentation.

Methods: We conducted a retrospective cross-sectional study of documented standardized GOC template notes for seriously ill hospitalized adult patients across 21-hospitals between 2021 and 2023.

Population Health Management for Improving Kidney Health Outcomes.

Chronic kidney disease (CKD) is globally prevalent, a leading cause of mortality, and is associated with poor patient outcomes and high health care costs. Gaps in guideline-concordant care are common across the continuum of CKD. These gaps lead to CKD progression, hospitalizations, and mortality and are potentiated by existing racial and socioeconomic disparities.

How Do Clinicians Use Quotations in Goals of Care Notes?

Background: Quoting patients in electronic medical record (EMR) notes is controversial. Quotations may be used to promote accuracy in documentation. However, they also may be used to cast skepticism on patient speech.

Artificial intelligence for better goals of care documentation.

Objectives: Lower rates of goals of care (GOC) conversations have been observed in non-white hospitalised patients, which may contribute to racial disparities in end-of-life care. We aimed to assess how a targeted initiative to increase GOC documentation rates is associated with GOC documentation by race.

Methods: We retrospectively assessed GOC documentation during a targeted GOC initiative for adult patients with an artificial intelligence predicted elevated risk of mortality.

Equity in Using Artificial Intelligence Mortality Predictions to Target Goals of Care Documentation.

Background: Artificial intelligence (AI) algorithms are increasingly used to target patients with elevated mortality risk scores for goals-of-care (GOC) conversations.

Objective: To evaluate the association between the presence or absence of AI-generated mortality risk scores with GOC documentation.

Design: Retrospective cross-sectional study at one large academic medical center between July 2021 and December 2022.

Advanced Care Planning in Chronic Kidney Disease: Qualitative Impact of the MY WAY Intervention.

Context: Despite recommendations for shared decision-making and advanced care planning (ACP) for people with chronic kidney disease (CKD), such conversations are infrequent. The MY WAY educational and patient coaching intervention aimed to promote high-quality ACP.

Objectives: This qualitative substudy sought to gain participant feedback on the MY WAY ACP coaching intervention, and how it impacted their wishes, perceptions of kidney care, and factors that helped them reflect on ACP.

Shared Decision-Making and Patient Communication in Nephrology Practice.

Shared decision-making (SDM) is the standard of care for patient or surrogates and their clinicians to arrive at a medical decision. Evidence suggests that SDM increases patients' understanding of their illness and satisfaction with their decision-making process. Dialysis patients often report the perception that they were passive participants in the decision to start dialysis, suggesting further opportunities for enhancing the application of SDM in decision-making with patients with kidney disease.

Concurrent Hospice and Dialysis Care: Considerations for Implementation.

Importance: Hospice positively impacts care at the end of life for patients and their families. However, compared to the general Medicare population, patients on dialysis are half as likely to receive hospice. Concurrent hospice and dialysis care offers an opportunity to improve care for people living with end-stage kidney disease (ESKD).

Implementing a Serious Illness Risk Prediction Model: Impact on Goals of Care Documentation.

Context: Goals of care conversations can promote high value care for patients with serious illness, yet documented discussions infrequently occur in hospital settings.

Objectives: We sought to develop a quality improvement initiative to improve goals of care documentation for hospitalized patients.

Methods: Implementation occurred at an academic medical center in Pittsburgh, Pennsylvania.

Hospice Care in Conservative Kidney Management.

Hospice care offers multidisciplinary expertise to optimize symptom management and quality of life for patients with limited life expectancy and help ensure that patients receive care that reflects their personal goals and values. Many patients receiving conservative kidney management (CKM) and their loved ones can benefit from the additional support that hospice provides, particularly as symptom burdens and functional status worsen over the last few months of life. We provide an overview of hospice services and how they may benefit patients receiving CKM, describe the evolution of optimal CKM strategies and collaboration between nephrology and hospice clinicians over the course of disease progression, and explore challenges to effective hospice care delivery for patients with chronic kidney disease and how to address them.

Delivery of Active Medical Management without Dialysis through an Embedded Kidney Palliative Care Model.

Background: Patients with CKD have high symptom burden, low rates of advance care planning (ACP), and frequently receive care that is not goal concordant. Improved integration of palliative care into nephrology and access to active medical management without dialysis (AMMWD) have the potential to improve outcomes through better symptom management and enhanced shared decision making.

Methods: We describe the development of a kidney palliative care (KPC) clinic and how palliative care practices are integrated within an academic nephrology clinic.

Description and Outcomes of an Innovative Concurrent Hospice-Dialysis Program.

Background: Compared with the general Medicare population, patients with ESKD have worse quality metrics for end-of-life care, including a higher percentage experiencing hospitalizations and in-hospital deaths and a lower percentage referred to hospice. We developed a Concurrent Hospice and Dialysis Program in which patients may receive palliative dialysis alongside hospice services. The Program aims to improve access to quality end-of-life care and, ultimately, improve the experiences of patients, caregivers, and clinicians.

Serious Illness Communication Skills Training during a Global Pandemic.

Background: Communication skills is a core competency for critical care fellowship training. The coronavirus disease (COVID-19) pandemic has made it increasingly difficult to teach these skills in graduate medical education. We developed and implemented a novel, hybrid version of the Critical Care Communication (C3) skills with virtual and in-person components for pulmonary and critical care fellows.

Clinicians' Perceptions of Collaborative Palliative Care Delivery in Chronic Kidney Disease.

Context: Guidelines recommend palliative care for patients with chronic kidney disease (CKD), who experience a high pain and symptom burden, and receive intensive treatments that often do not align with their values. A lack of scalable specialty palliative care services has prompted calls for attention to primary palliative care, delivered in primary care and nephrology settings.

Objectives: The objectives of this study were to 1) describe expectations for care to meet the palliative care needs of people living with CKD, and limitations to meeting those expectations in the current model, and 2) identify potential interventions to meet patients' palliative care needs.

Video Images about Decisions for Ethical Outcomes in Kidney Disease (VIDEO-KD): the study protocol for a multi-centre randomised controlled trial.

Introduction: Older patients with advanced chronic kidney disease (CKD) often are inadequately prepared to make informed decisions about treatments including dialysis and cardiopulmonary resuscitation. Further, evidence shows that patients with advanced CKD do not commonly engage in advance care planning (ACP), may suffer from poor quality of life, and may be exposed to end-of-life care that is not concordant with their goals. We aim to study the effectiveness of a video intervention on ACP, treatment preferences and other patient-reported outcomes.

Implementation of Surprise Question Assessments using the Electronic Health Record in Older Adults with Advanced CKD.

Background: The Surprise Question (SQ; "Would you be surprised if this patient died in the next 12 months?") is a validated prognostication tool for mortality and hospitalization among patients with advanced CKD. Barriers in clinical workflows have slowed SQ implementation in practice.

Objectives: The aims of this study were: () to evaluate implementation outcomes after the use of electronic health record (EHR) decision support to automate the collection of the SQ; and () to assess the prognostic utility of the SQ for mortality and hospitalization/emergency room (ER) visits.

Communication Skills Training for Nurses and Social Workers: An Initiative to Promote Interdisciplinary Advance Care Planning and Palliative Care in Patients on Dialysis.

Palliative care initiatives are needed in nephrology, yet implementation is lacking. We created a 6-hour workshop to teach the skills of active listening, responding to emotion, and exploring goals and values to nurses and social workers working in dialysis units. The workshop consisted of interactive didactics and structured role play with trained simulated patients.

Advance Care Planning Coaching in CKD Clinics: A Pragmatic Randomized Clinical Trial.

Rationale & Objective: Although guidelines recommend more and earlier advance care planning (ACP) for patients with chronic kidney disease (CKD), scant evidence exists to guide incorporation of ACP into clinical practice for patients with stages of CKD prior to kidney failure. Involving nephrology team members in addition to primary care providers in this important patient-centered process may increase its accessibility. Our study examined the effect of coaching implemented in CKD clinics on patient engagement with ACP.