Improving Goals of Care Discussions in Nephrology

Improving Goals of Care Discussions in Nephrology
Program proves training can bolster skills needed for difficult conversations.

While discussing goals of care is essential when patients have advanced kidney disease approaching dialysis, too few nephrologists have the skills and comfort level to facilitate these conversations. Providing trainees with a focused educational program can have a measurable impact on their skillset to initiate these discussions, according to research published in the Journal of Palliative Medicine led by Devika Nair, M.D.

“Many nephrologists avoid or delay discussing death, dying and prognosis,” said Nair, an instructor in the Division of Nephrology and Hypertension at Vanderbilt University Medical Center. “This lack of communication often results in fear, anxiety and regret on the part of our patients. Evidence supports that patients value transparency, even if they hear bad news.”

“Lack of communication often results in fear, anxiety and regret on the part of our patients. Evidence supports that patients value transparency, even if they hear bad news.”

Nair and colleagues1 purposefully designed a program that would integrate seamlessly into trainees’ clinical rotation. “Nephrology fellows ordinarily have to take time out of their packed schedules and travel long distances to receive this kind of training,” Nair said. Training can be expensive and doesn’t always involve the kind of direct mentorship from palliative subspecialists included in their program, she added.

Testing the Value of Education

To test the value of a training program focused on goals of care discussions, Nair and colleagues evaluated before-and-after knowledge and confidence related to such discussions in a cohort of 16 nephrology trainees (8 female; 8 male; average age 33).

At the beginning of the academic year, trainees received relevant readings and attended a didactic session on prognostication and discussing goals of care led by Nair and a palliative care subspecialist, Mohana Karlekar, M.D., chief of palliative care medicine at Vanderbilt. Throughout the year, participants received a list of hospitalized kidney disease patients who were appropriate for an advanced care planning consultation by the educational team.

Trainees met with patients in the presence of an on-call palliative care specialist to conduct the conversation themselves or observe the specialist’s discussion with the patient. Afterward, the trainee received feedback from the specialist.

Evidence of Behavior Change

After the training, Nair conducted semi-structured interviews with participants to assess: (1) their prior knowledge regarding goals of care conversations and prognostication; (2) their attitudes towards such conversations (responsibility to initiate, comfort, etc.); and (3) changes in their ability to identify appropriate patients and speak with them in a timely manner.

All 16 trainees reported increased comfort with and likelihood to initiate goals of care conversations in the future. Twelve reported a better ability to identify appropriate patients for advance care planning. Only two trainees who had previously had extensive exposure to advanced care planning reported no perceptions of behavior change.

“This program may offer a novel, feasible and possibly scalable way to spur behavior change among nephrologists and encourage timely discussions around goals of care,” Nair said.

Expanding the Program

Recently, Nair’s team developed a simulated patient session through Vanderbilt’s Center for Experiential Learning and Assessment that allows trainees to engage in a dialysis decision-making conversation with a standardized patient. Other nephrology fellowship programs have expressed interest in incorporating similar electives into their curriculums, Nair said.

The team plans to expand the program so trainees can establish longer-term relationships with patients. They also foresee incorporating strategies to address prognostic uncertainty in dialysis decision-making.

“Shared decision-making involves partnering with patients to make treatment decisions that align with their goals and values,” Nair said. “Part of that process involves communicating uncertainty.  To communicate prognostic uncertainty to our patients, we need to first become comfortable accepting uncertainty ourselves.

“Shared decision-making involves partnering with patients to make treatment decisions that align with their goals and values. Part of that process involves communicating uncertainty.”