Improving Supportive Care of Seriously Ill Dialysis Patients with Goals-of-Care Conversations

Background: Dialysis patients are frequently known to receive unwanted high intensity end-of-life care Families rate the quality of this care lower than families of patients with other chronic diseases The purpose of this study was to test the feasibility of a supportive care intervention-the Pathways Project, an evidence-based change package of best practices-to identify seriously ill patients (SI), engage them in goals of care discussions, and track outcomes for patient goal concordance Methods: Pathways researchers recruited 10 dialysis centers with 1,546 patients Dialysis staff screened patients with the surprise question (SQ)-“Would I be surprised if this patient died in the next 6-12 months?”- to identify those who were SI and recorded patient outcomes including the number screened, SI, goals of care conversations, hospitalizations, referred to hospice, death, and place of death An odds ratio was calculated for the odds of SI dying versus those who were not SI, and one-sided Cochran- Armitage trend tests were used to assess for increasing goals of care conversations and deaths at home The study was interrupted at 9 months due to COVID-19 Results: On average, 98 8% of patients were screened monthly, and 18 4% were identified as SI Of 114 patients who died, the SI constituted 66% of deaths though only 18 4% of patients The mortality for the SI was 27% versus 3% for those who were not, and the odds ratio for SI dying was 11 22 (95% CI 7 42 to 16 98, P < 0001) Dialysis interdisciplinary teams implemented site-specific approaches to adding goals of care conversations into usual workflow;the number conducting conversations with SI within 30 days of hospital discharge increased from 30% to 80% (P= 02) The proportion of the patients who died at home in the last 2 months was higher than baseline (32 6% vs 18 8%), but a trend was not yet evident (P= 12) Conclusions: The Pathways intervention is feasible to implement supportive care best practices into existing workflow of dialysis centers It takes time for teams to get comfortable with new processes and communication approaches;after 9 months more centers were conducting goals of care conversations and more patients were dying at home Future research is needed to determine if the Pathways intervention results in outcomes more aligned with patient preferences