Palliative care experience of US adult nephrology fellows: a national survey

Figures & data

Table 1. Palliative care experience of US adult nephrology fellows: survey questions.

1. What year of fellowship you are currently in? (91%)

• First year

• Second year

• Third year

• >3 years

2. What is your age? (92%)

• 20–25

• 26–30

• 31–35

• >35

3. What is your religious preference? (92%)

• Hinduism

• Christianity

• Islam

• Judaism

• Buddhism

• Sikhism

• Other

• None

4. What is your gender? (92%)

• Male

• Female

5. Did you go to medical school in United States? (92%)

• Yes

• No

6. What is your ethnic background? (92%)

• Caucasian

• African American

• Latino

• Asian

• American Indian

• South East Asian

• Other

7. Which region of the United States is your fellowship program located? (92%)

• North East

• Mid West

• South

• West

• Other

8. Your Fellowship is a_______ (92%)

• University based/medical school based program

• Community hospital based program

9. Did you participate in a formal palliative care rotation during your medical school? (92%)

• Yes

• No

10. Did you participate in a formal palliative care rotation/elective during your medical residency? (92%)

• Yes, a one week rotation

• Yes, a two week rotation

• Yes, a four week rotation

• Yes, more than four week rotation

• No formal training in palliative care

11. Does your hospital have a Division or Department of Palliative Care Medicine? (91%)

• Yes

• No

• Don’t know

12. Do you have formal didactic experience in the field of palliative care (lectures and conferences) as part of core curriculum during your fellowship? (92%)

• Yes

• No

• Don’t know

13. Does your current fellowship offer formal clinical training in palliative care? (91%)

• Yes

• No

14. Do you think a palliative care elective/rotation during the tenure of your fellowship will help you make thoughtful decisions? (92%)

• Yes

• No

• I already had or will have such experience during my fellowship

• Don’t know

15. Which of the following would you benefit most from a palliative care rotation during your fellowship? (Please check all that apply) (90%)

• How to run a family meeting

• How to discuss DNI/DNR

• How not to offer aggressive medical management

• How to discuss withdrawal of life supporting measures

• Learning about what “palliative care” means

• What are the benefits of hospice

• Sitting in on a family meeting

16. Please comment on the duration and nature of the palliative care elective you would like during your training? (free comment section) (40%)

17. What do you feel most comfortable with? (click all that apply) (91%)

• Writing hemodialysis orders on a chronic outpatient unit

• A consult in the ICU

• Writing continuous dialysis orders in the ICU

• Not offering dialysis to a patient with multi-organ failure in ICU

• Treating rapidly progressive glomerulonephritis

• Performing an ultrasound guided kidney biopsy

18. How comfortable do you feel? (91%)

• Not offering or withholding renal replacement therapy

1. 2. 3. 4. 5. (1 being least comfortable, 5 being most comfortable)

Withdrawing renal replacement therapy

1. 2. 3. 4. 5. (1 being least comfortable, 5 being most comfortable)

Managing pain with medications in a patient with advanced renal disease

1. 2. 3. 4. 5. (1 being least comfortable, 5 being most comfortable)

Treating depression in dialysis patients

1. 2. 3. 4. 5. (1 being least comfortable, 5 being most comfortable)

Having end of life discussions with patients on dialysis

1. 2. 3. 4. 5. (1 being least comfortable, 5 being most comfortable)

19. As a fellow have you ever had end-of-life discussions with advanced kidney disease patients? (91%)

• Less than 5 encounters

• 5–10 encounters

• >10 encounters

• Never

20. Do you feel obligated to offer renal replacement therapy to every patient regardless of benefit? (89%)

• Yes

• No

Note: Response rate is indicated in the parentheses.

Figure 1. Palliative care experience during nephrology fellowship.

Figure 2. Formal palliative care rotation during medical school or residency: USMGs compared to IMGs (Data are given in percentages). USMGs, US medical graduates; IMGs, international medical graduates.

Figure 3. Comfort level of US adult nephrology fellows on palliative care related issues (1: being least comfortable, 5: being most comfortable. Data are given in percentages).

Figure 4. End-of-life discussions with patients with advanced renal disease.

Figure 5. Perceived benefits of palliative care rotation during nephrology fellowship.

Table 2. Resources for faculty and trainees on renal palliative care.

1. Clinical Practice Guideline

Renal Physicians Association. Shared Decision-Making in the Appropriate Initiation of and Withdrawal from Dialysis, 2nd ed. Rockville, MD: Renal Physicians Association, 2010.

Moss AH. Revised Dialysis Clinical Practice Guideline Promotes More Informed Decision-Making. Clin J Am Soc Nephrol 2010;5(12):2380–2383

Moss AH, Holley JL, Davison SN, Dart RA, Germain MJ, Cohen LM, Swartz RD. Core Curriculum in Nephrology: Palliative Care. Am J Kidney Dis 2004;43:172–185.

Davison SN. The ethics of end-of-life care for patients with ESRD. Clin J Am Soc Nephrol 2012;7(12):2049–2057

Germain MJ, Davison SN, Moss AH. When Enough Is Enough: The Nephrologist’s Responsibility in Ordering Dialysis Treatment. Am J Kidney Dis 2011;58(1):135–143.

Moss AH. Ethical Principles and Processes Guiding Dialysis Decision-Making. Clin J Am Soc Nephrol 2011;6(9):2313–2317

2. RPA/ASN Position Statement

Renal Physicians Association. American Society of Nephrology: Position Paper on Quality Care at the End of Life. Rockville, MD: Renal Physicians Association, 2002.

3. Book

Chambers EJ, Germain M, Brown E, eds. Supportive Care for the Renal Patient, 3rd ed. Oxford: Oxford University Press, 2012.

4. Web Resources

http://www.asn-online.org/education/distancelearning/curricula/geriatrics/

http://www.asn-online.org/kidneydisease/geriatrics/rounds/

http://www.choosingwisely.org/doctor-patient-lists/american-society-of-nephrology/

http://www.kidneysupportivecare.org/Files/Bibliography5292013.aspx

5. Patient-Friendly Resources

Callanan, M., Kelley, P. (1993). Final Gifts: Understanding the Special Awareness, Needs, and Communications of the Dying. New York: Bantam.

Dunn, H. (2001). Hard Choices For Loving People: CPR, Artificial Feeding, Comfort Care, and the Patient with a Life-Threatening Illness.

http://www.hnehealth.nsw.gov.au/__data/assets/pdf_file/0016/54250/HardChoices.pdf.

Okun, B., Nowinski, J. (2011). Saying Goodbye: How Families Can Find Renewal Through Loss. New York: The Berkley Publishing Group.

Webb, M. (1997). The Good Death: The New American Search to Reshape the End of Life. New York: Bantam.

 Note: Full set of resources can be found at http://www.kidneysupportivecare.org/Files/Bibliography5292013.aspx (Adopted from the website with permission).