K NGUYEN1, S SINHA1, B HENDERSON1, S WONG1, S ROXBURGH1
1Department of Renal Medicine, Royal North Shore Hospital, Sydney, NSW.
Background: Older patients have a higher burden of morbidity/mortality when treated with dialysis for end stage kidney disease (ESKD), particularly if they have multiple comorbidities. An increasing number of ESKD patients thus elect for a renal supportive care (RSC) pathway. A percentage of these then undergo a “change of heart” (COH). There is limited data in the literature about outcomes in this group.
Methods: We conducted a single centre retrospective review of our CKD nurse educator database, identifying those who elected RSC but then changed to a dialytic pathway. We cross referenced against hospital medical records and our general renal unit database. We evaluated baseline demographics, the reasons behind the changed decision, and subsequent morbidity/ mortality.
Results: Between 2012 and 2017, 8 patients have undergone a COH at our institution. Mean age; 72.9 years, mean number of comorbidities; 6 per patient. Male; female ratio; 3;1.6 of 8 had undergone CKD education, and clearly elected RSC. 5 had a COH during hospital admission for acute on chronic renal decline. 5 were still living, with 3 deceased by study end. Average length of hospitalisation; 44.9 days after COH, with an average of 5.1 emergency presentations/ hospitalisations per patient.
Conclusion: Many of the patients in this case series underwent a COH during a period of acute illness, when faced with life-threatening decompensation. Despite COH, they faced long and multiple hospitalisations. Recommendations for improvement include clearer inter-institutional communication and coordination, early engagement of specialist palliative care services, and regular discussions with the patient and key family members.