SUN-092 WHAT IS RENAL SUPPORTIVE CARE AND HOW DOES IT DIFFER FROM PALLIATIVE CARE? OUTCOMES FROM A MIXED METHODS STUDY

Abstract

Patients with end stage kidney disease (ESKD) report high symptom burden, complex care needs and often have limited prognosis. Renal supportive care (RSC) is a clinical approach aiming to improve quality of life (QOL). In the absence of standardised and widely accepted definitions, clinicians’ perceptions of RSC and its’ role alongside specialist palliative care (SPC) and referral practises are unknown. An exploratory qualitative study was conducted across 3 metropolitan and 2 regional Victorian hospitals. Focus groups of renal clinicians were audio recorded and transcribed for thematic analysis using grounded theory by two independent researchers. This informed the second phase validated online survey undertaken between February and June 2018. Participants completed demographic details, views and referral practises of RSC and SPC. Univariate analysis used Pearson’s chi squared test and multivariate logistic regression analysis identified predictors of referral. Of clinicians recruited for phase 1 (n=58), there were 35 nurses and 23 doctors. Clinical experience ranged 0.5-40 years. Key themes from the qualitative study included clinician distress around end of life decision making, challenges in identifying transition points to herald the final phase of life and lack of clarity and variable understanding of renal supportive care. Participants (n=382) recruited for phase 2 are listed in Table 1. Respondents are confident they know what RSC is (93%) and that it is a term used in clinical practice (63%). Most clinicians perceive RSC as different to (77%) and more acceptable (80%) than SPC and few (5%) agreed when they refer to RSC they are no longer involved in care. RSC is viewed as improving symptoms and QOL (89%), equivalent to conservative care (30%), active treatment (72%) and part of usual care for CKD patients (40%). Most (79%) agreed it is useful to have more defined triggers for referral and 55% thought renal clinicians are skilled in RSC. Referral to RSC was favoured over SPC for all indications except when the patient was actively dying (Table 2). Clinicians are more likely to refer for symptom management to RSC if it is viewed as more acceptable than SPC (OR 2.39 CI 1.16-4.1, p=0.02). Nurses are more likely to consider RSC referral than doctors for patients with; - limited prognosis (OR 4.65 CI 1.60-13.55 p=0.01) - requests to stop dialysis (OR 4.35 CI 1.27-14.88 p=0.02) - inability to continue dialysis (OR 3.98 CI 1.33-11.97 p=0.01) - assistance with complex treatment decision making (OR 2.77 CI 1.25-6.14 p=0.01) - clinical deterioration (OR 2.69 CI 1.011-7.17 p=0.05) other factors including gender, experience and location did not significantly predict referral.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Perceptions and understanding of RSC are variable; however it is distinct and more acceptable than SPC. RSC is considered integrated, active management focused on improving symptoms and QOL well before the final weeks of life. There is perceived overlap in function of RSC and SPC therefore presenting prospects for further clarification and collaboration. Given the challenges identified at the end of life, this study also revealed opportunities to improve new and existing RSC and SPC education and services to assist ESKD patients.