ABSTRACT
OBJECTIVES: Extensive discussion with renal patients about treatment intensity is not systematically integrated into their care and often occurs during an acute hospitalization. We conducted a "test-of-change" pilot study to assess the utility of providing an upstream discussion in the ambulatory setting as an additional nephrology consult to assist patients with chronic kidney disease considering treatment choices. METHODS: We randomly assigned patients with Stage 4 or Stage 5 chronic kidney disease who had not yet begun renal dialysis to 1 of 2 groups. The test group received the additional nephrology consult and met with an interdisciplinary team composed of a nephrologist, social worker, and clinical ethicist, and the control group did not. Qualitative data were collected in 2012 and 2013 via oral questionnaire. Both groups received a 6-month follow-up assessment. RESULTS: Patients who received the nephrology consult reported that they experienced help in forming a treatment plan, felt well understood, and had the opportunity to thoroughly discuss questions. The controls had a 26% increased probability of beginning dialysis and had a statistically significant increase in dialysis and clinic visits (p < 0.10 and p < 0.05). Controls also were likelier than the test group to be admitted to the hospital (0.5 vs 0.2 admissions per patient in the test group), spend more days hospitalized (2.8 vs 0.5 bed days per patient), and visit the emergency room (0.73 vs 0.66 visits per patient) and clinic (6.6 vs 3.6 visits per patient). CONCLUSIONS: An additional nephrology consultation proved helpful both qualitatively and quantitatively.
Subject(s)
Nephrology , Referral and Consultation/standards , Renal Dialysis , Renal Insufficiency, Chronic/therapy , Adult , Ambulatory Care Facilities , Communication , Decision Making , Female , Humans , Male , Middle Aged , Patient Participation , Patient Satisfaction , Pilot ProjectsABSTRACT
OBJECTIVE: This study identified and measured common patterns of patients' positive care experiences during inpatient palliative consultation, and helped better understand how the journey of discovery experienced by both patients and life-care consult teams can be used to improve the quality of care. METHODS: We administered questionnaires to a convenience sample of 25 patients who were referred to inpatient palliative care for a goals-of-treatment consult between April 2010 and May 2012. RESULTS: The codified responses to questionnaires revealed the perspectives of our patients rather than predicting outcomes. Respondents identified six areas of satisfaction: treatment with dignity and respect by the hospital health care team; after life-care planning consultation, patients felt they were better informed of their illness and medical context; 95% of all patients who responded felt their overall experience was excellent; all respondents felt the life-care planning consultation helped them form a treatment plan; all patients who responded believed their cultural beliefs and values were respected; and all responding patients noted that the inpatient palliative care team adequately addressed pain and symptom control. CONCLUSION: We were encouraged by our findings: the feedback from patients and families showed us we were effective, from their perspective, in helping them shape their treatment journey. It also emphasized where we could have been even more effective in improving our communication.
Subject(s)
Palliative Care/standards , Patient Satisfaction , Quality of Health Care/standards , Referral and Consultation/standards , Communication , Humans , Professional-Patient Relations , Qualitative Research , Surveys and QuestionnairesABSTRACT
CONTEXT: Many patients and their families have difficulty making decisions when confronted with complex medical problems. Often their expectations and hopes are beyond what medical science can deliver, and at times their desires seem to conflict with their treatment plans. Additionally, costly tests and treatments with little or no benefit are often explored. Inpatient palliative care consultation services for end-of-life-care planning can help patients navigate this complexity, arrive at a care plan consistent with their personal values, and be good stewards of precious medical resources. OBJECTIVE: We conducted a study to assess the effect that one function of our organization's Inpatient Palliative Care Service-consultation regarding end-of-life-care planning-has on readmission rates. We believed that our study would show that interdisciplinary end-of-life-care planning improves resource use by reducing the probability and rate of hospital readmission. METHODS: We retrospectively reviewed electronic records for Kaiser Permanente HealthConnect at Kaiser Permanente South Bay Medical Center in Harbor City, CA, for 200 consecutive patients referred to our Inpatient Palliative Care Service between November 2006 and February 2010, comparing hospital readmissions between two groups of patients. Members of both groups (100 patients in each) all had an Inpatient Palliative Care consult ordered for end-of-life-care planning; members of group A were seen solely by an inpatient palliative care registered nurse (RN), whereas members of group B were seen by an interdisciplinary team consisting of a physician, a bioethicist, a social worker, an RN, and a hospital chaplain. RESULTS: We found that with the post-team consultation, readmissions to the hospital per patient per six months after consultation decreased from 1.15 to 0.7 admissions per patient.
