Introduction
Renal inpatients often comprise a co-morbid and frail cohort that are vulnerable to clinical deterioration while in hospital.1 Risk factors include higher rates of major adverse cardiovascular events and opportunistic infections, particularly in immunosuppressed patients with glomerulonephritis or in those with a kidney transplant.2–4 Given that renal healthcare professionals frequently care for such a cohort as inpatients, it would seem plausible that they are confident and competent with advanced care planning (ACP) discussions particularly focusing on resuscitation and treatment escalation plans (TEP). We sought to assess attitudes and practices, relating to ACP for inpatients, among healthcare professionals working in the renal department of the Royal Free Hospital in order to identify barriers to timely discussions on TEP.
Materials and methods
A self-devised, anonymous survey of 22 questions on ACP was piloted and distributed to all healthcare professionals working within inpatient renal services.
Results and discussion
Preliminary results are available from eight consultants, seven junior doctors and 10 allied healthcare professionals, 84% of whom had been involved in ACP decisions in the past year (February 2021–22). Only 28% reported to have previously received relevant training. When asked who was best placed to contribute to ACP decisions, the majority (88%) selected the admitting or ward doctors. Although, a significant number also chose the nurse in charge of the ward (56%), intensive care team (32%) and palliative care teams (48%). Almost two-thirds of respondents believed that the ideal time to establish a TEP was on admission (68%) and that an early TEP was essential to good patient care (64%). Three respondents felt that a do not resuscitate order resulted in poorer access to medical care. The COVID-19 pandemic was deemed by 92% to have had at least a moderate effect on TEP. A third of respondents demonstrated concern that TEP and resuscitation plans were not considered appropriately on a frequent basis for renal inpatients. The most common barriers cited to hindering ACP discussions were limited time to explore such issues and anxieties relating to inciting fear or anger in patients and key contacts. Most respondents felt very confident in their ability to explore current medical issues (80%) and co-morbidities (76%) but less than two-thirds expressed similar confidence in assessments of physiological baseline (48%), functional baseline (56%), frailty (52%) and prognosis (24%). The survey also identified problems with documentation of TEP and resuscitation plans on our electronic patient record (EPR) system and access to community records for pre-existing ACP.
Conclusion
Our results demonstrate underconfidence and anxieties in healthcare professionals when approaching ACP in renal inpatients, with a significant proportion concerned that TEP were not frequently considered appropriately. Training in recognising frailty and its impact on prognosis may likely improve the confidence and quality of TEP completed. An audit of inpatient TEP discussion and documentation is currently in progress. Improvements in documentation and communication, achieved through local retraining, will be critical to improving TEP for renal patients and avoid unnecessary or harmful treatments in the frail and vulnerable.
- © Royal College of Physicians 2022. All rights reserved.
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