Date of Graduation

Fall 12-11-2020

Document Type

Project

Degree Name

Doctor of Nursing Practice (DNP)

College/School

School of Nursing and Health Professions

Department/Program

Nursing

Program

Executive Leader DNP

First Advisor

Sara Horton-Deutch

Second Advisor

Jim D'Alfonso

Abstract

Palliative care prevents and relieves suffering through the early identification and treatment of pain and other symptoms, which can be physical, psychosocial, or spiritual (World Health Organization, 2018). It is usually considered a service provided to oncology patients and has positively impacted their treatment. However, it is not as common for many other diseases where the patient would benefit from palliative care involvement. Presently, if palliative care is offered to nephrology patients, it is after they have started dialysis and are having second thoughts whether to continue this treatment plan as it has either become less effective or is interfering with the patient’s quality of life. It has been demonstrated that elderly patients with co-morbidities might only derive limited survival benefits from dialysis Stopping the dialysis usually leads to imminent death, while those on conservative treatment may live up to an additional 23.4 months (Seccareccia & Downar, 2012). Although Scherer et al. (2018), developed an integrated nephrology and palliative care program, others have been slow to adopt this type of care. The focus of this project was to determine by offering palliative care to patients at earlier stages of Chronic Kidney Disease (CKD), would they accept the intervention and think about what they would like as their goals of care?

The patient panel of one nephrologist from a large urban medical center in the San Francisco Bay Area was used, and those patients who were at CKD stages 3B or 4 were selected for the project. Those patients on the list who already were on dialysis were on the hospital’s palliative care registry or life care planning registry or had previously had a palliative or life care planning consult were eliminated. This left 26 patients who were contacted, 14 patients made appointments, ten had consults, and four did not keep their appointment. After the consultation, four of the patients stated they were interested in conservative treatment. The youngest of these was 57, and the oldest was 82. All these patients had low Tangri scores, which predicted that they had time before reaching end stage renal disease (ESRD), the point at which they would need dialysis.

The project demonstrates that with a palliative care consultation early in the disease process the patient can make informed decisions about their goals of care without being in a crisis state. By explaining to the patient that this is normal care that is ordered by their physician, more patients were willing to accept the consultation, and not think they were being handed a death sentence. These patients received palliative care early enough in their illness, so they had time to decide on their own goals of care and have the opportunity to receive ongoing support as their disease progresses. The National Kidney Foundation (NKF) promotes the use of early palliative care for patients with kidney disease, but the medical community is not always willing to accept conservative treatment as they view dialysis as the gold standard ("Starting or stopping dialysis," 2019). As supported by the literature, early palliative care in any life-limiting disease should be a best practice, just as it is for Oncology patients.

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