S SWAMINATHAN 1,2
1John Hunter Hospital, Newcastle, Australia, 2Royal North Shore Hospital, St Leonards, Sydney, Australia
Aim: To improve the uptake of Advanced Care Directives for haemodialysis patients at Royal North Shore Hospital.
Background:Prior to COVID-19 it had been a longstanding interest of this Renal Department to improve the uptake of Advanced Care Directives (ACDs) in haemodialysis patients. Patients on haemodialysis were recognised as particularly vulnerable to COVID-19 in the setting of frequent hospital presentations for treatment, increased risk of transmission and significant burden of comorbidities with a concern that deteriorating patients may receive invasive treatments that were inappropriate or against their wishes.
Methods: Members of the Renal Supportive Care team at Royal North Shore Hospital established a database of in-hospital and adjacent satellite haemodialysis patients at the start of the initiative. Over 4 months, the team visited the haemodialysis centres to engage patients in 15-30 minute conversations about their wishes for future care. These patients were further followed up over the 4 months.
Results: At the beginning of the initiative there were 136 patients across both haemodialysis centres with 21 (15%) who had completed ACDs. Over more than 70 initial conversations and a further 64 follow up conversations this was increased more than double to 48 (35%) of the total initial 136 patients. 7 patients died during the initiative period within appropriate ceilings of care.
Flow analysis of the kidney showed LPS-TolDC localise to the kidney (7.7 vs 3.5 % CD45+, p <0.001 compared to TolDC) but there was no significant difference in absolute CD45+, or proportions of T-, neutrophils or myeloid cells between LPS-TolDC and controls. Despite differences in subsets based on CD11b, CD11c, F4/80 and Ly6C, depletion of recipient myeloid cells with liposomal clodronate did not impair the reno-protective capacity of AlloTolDC (creatinine 30.6±19umol vs 155±44.7umol/L, p<0.001).
Conclusion: Within the scope of the initiative and despite several challenges faced by the team the initiative was overall very successful. The lessons learned from the initiative pave the way for promoting discussion of advanced care planning as part of the dialysis consent and initiation process as a standard of care as well as establish future plans for tracking resuscitation status
Shriram Swaminathan is a Renal Advanced Trainee at John Hunter Hospital. He has previously done training in Renal Supportive Care at Royal North Shore Hospital. Shriram plans to practice as a clinical nephrologist in a teaching hospital with a particular interest in renal supportive care and managing frailty and symptom support in chronic kidney disease.