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Original ArticlesHealth Services Research
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Conservative Care for ESRD in the United Kingdom: A National Survey

Ikumi Okamoto, Sarah Tonkin-Crine, Hugh Rayner, Fliss E.M. Murtagh, Ken Farrington, Fergus Caskey, Charles Tomson, Fiona Loud, Roger Greenwood, Donal J. O’Donoghue and Paul Roderick
CJASN January 2015, 10 (1) 120-126; DOI: https://doi.org/10.2215/CJN.05000514
Ikumi Okamoto
*Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, United Kingdom;
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Sarah Tonkin-Crine
*Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, United Kingdom;
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Hugh Rayner
†Department of Renal Medicine, Heart of England NHS Foundation Trust, Birmingham, United Kingdom;
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Fliss E.M. Murtagh
‡Department of Palliative Care, Policy and Rehabilitation, King’s College London, London, United Kingdom;
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Ken Farrington
§Renal Unit, Lister Hospital, Stevenage, United Kingdom;
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Fergus Caskey
‖Renal Unit, Southmead Hospital, Bristol, United Kingdom;
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Charles Tomson
‖Renal Unit, Southmead Hospital, Bristol, United Kingdom;
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Fiona Loud
¶British Kidney Patient Association, United Kingdom; and
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Roger Greenwood
§Renal Unit, Lister Hospital, Stevenage, United Kingdom;
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Donal J. O’Donoghue
**Department of Renal Medicine, Salford Royal NHS Foundation Trust, Salford, United Kingdom
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Paul Roderick
*Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, United Kingdom;
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Abstract

Background and objectives Conservative kidney management (CKM) has been developed in the United Kingdom (UK) as an alternative to dialysis for older patients with stage 5 CKD (CKD5) and multiple comorbidities. This national survey sought to describe the current scale and pattern of delivery of conservative care in UK renal units and identify their priorities for its future development.

Design, setting, participants, & measurements A survey on practice patterns of CKM for patients age 75 and older with CKD5 was sent to clinical directors of all 71 adult renal units in the UK in March 2013.

Results Sixty-seven units (94%) responded. All but one unit reported providing CKM for some patients. Terminology varied, although "conservative management" was the most frequently used term (46%). Lack of an agreed-upon definition of when a patient is receiving CKM made it difficult to obtain meaningful data on the numbers of such patients. Fifty-two percent provided the number of CKM patients age ≥75 years in 2012; the median was 45 per unit (interquartile range [IQR], 20–83). The median number of symptomatic CKM patients who would otherwise have started dialysis was eight (IQR, 4.5–22). CKM practice patterns varied: 35% had a written guideline, 23% had dedicated CKM clinics, 45% had dedicated staff, and 50% provided staff training on CKM. Most units (88%) provided primary care clinicians with information/advice regarding CKM. Eighty percent identified a need for better evidence comparing outcomes on CKM versus dialysis, and 65% considered it appropriate to enter patients into a randomized trial.

Conclusions CKM is provided in almost all UK renal units, but scale and organization vary widely. Lack of common terminology and definitions hinders the development and assessment of CKM. Many survey respondents expressed support for further research comparing outcomes with conservative care versus dialysis.

  • conservative care
  • end-stage kidney failure
  • palliative care
  • national
  • survey
  • older adults

Introduction

The increase in the rate of RRT in recent decades has been greatest among elderly people, many of whom are frail and have multiple comorbid conditions (1,2). Starting dialysis was associated with a substantial and sustained decline in functional status among nursing home residents (3), and RRT may not be beneficial in the context of increasing frailty and loss of independence (4–6). A conservative care pathway is increasingly recognized as an alternative treatment to dialysis and has been introduced in the United Kingdom (UK) (1,6–10), Australia (11,12), other European countries (13–15), and Asia (16–18).

Conservative care for ESRD is evolving in the UK (19), and information on how it is practiced is limited to individual units. In 2005, Gunda et al. (20) reported significant variation in the provision of palliative care for ESRD across the UK. Lack of resources was identified as a major problem, and some units gave palliative care a low priority because of workload (20).

We present the results of a national survey of practice patterns for treating patients aged 75 years and older with CKD stage 5 (CKD5) receiving conservative care, termed conservative kidney management (CKM) for the purposes of this study.

Materials and Methods

The content of the survey was based on existing literature, a qualitative study of 60 staff interviews from a representative sample of nine renal units, and feedback from content experts on the project steering group. A draft survey was piloted using cognitive interviews with three nephrologists and one renal nurse specialist. Two forms of the survey were developed: web-based and paper-based. Contact details of clinical directors from all 71 adult renal units were obtained from the UK Renal Registry, and both forms of the survey were sent to them in March 2013 (see Supplemental Appendix 1 for the survey).

Data were analyzed using basic statistics. Cross-tabulation was conducted to explore the relationship between variation in practice patterns and potentially related factors: the number of patients receiving CKM, the availability of staff responsible for CKM, and the allocation of staff time to CKM. Units were categorized into two approximately equal groups according to their responses to the questions regarding the number of CKM patients age 75 and older in 2012 and the number of patients age 75 and older who stayed on CKM after they became symptomatic and would otherwise have started dialysis in the same year. Units that had >25 CKM patients or ≥20 symptomatic CKM patients were categorized as "larger" units. We related CKM size to the prevalent pool of patients age 75 and older who were receiving RRT (all were undergoing dialysis) in 2012 to examine whether this factor was associated with the development of the CKM program. The number of patients aged 75 and older who were receiving RRT was derived from UK Renal Registry data using the prevalent number of patients receiving RRT and the percentage of those aged 75 and older (21).

We tested for associations with these categorical variables using a chi-square test; given the potential for multiple testing and false-positive results we report only associations that were significant at P<0.01. To measure how much time renal staff were involved in CKM, the survey asked about full-time equivalent (FTE) time. An FTE of 1.0 indicates that a person is equivalent to a full-time worker, or two persons working half-time.

Results

Of the 71 UK adult renal units, 67 (94%) responded (50 of 52 units in England, five of five in Wales, eight of nine in Scotland, and four of five in Northern Ireland). The survey respondents’ roles varied; respondents described themselves as clinical leads (20), consultant nephrologists (17), nurses (15), and clinical directors (9). Thirty-two units indicated that the survey respondent consulted other staff member(s) when completing it. Thirty-seven completed the web version and 30 the postal version. Of the 67 units, two did not fully complete the survey, and one had no patients with CKD5 who had actively decided not to undergo dialysis; this unit was automatically directed to skip all questions related to CKM. Therefore, for many questions the total number of responses was <67.

All but one unit (66 of 67) had a CKM pathway. There was no agreed-upon terminology to describe this pathway, although "conservative management" was most frequently used (30 of 65 [46%]), followed by "conservative care management" (eight of 65 [12%]).

Size of Program

When asked how many patients with CKD5 age 75 and older were receiving CKM and followed up in their unit during 2012, 35 units (52%) provided data: The median was 45 (interquartile range [IQR], 20–83; range, 4–152) patients per unit. When asked how many patients aged 75 and older in their unit chose to have CKM, became symptomatic of advanced CKD, and were not undergoing dialysis, 33 (49%) units provided data; the median number of patients was eight (IQR, 4.5–22; range, 1–50). In total, 47 units provided data on the number of CKM patients age 75 and older or the number of CKM patients who were symptomatic. Twenty-four and 23 units were categorized as "larger" and "smaller," respectively; 20 were unclassifiable because of missing data.

Program Organization and Resourcing

Two thirds (43 of 65 [66%]) of units had a single person or a small team primarily responsible for CKM; all were consultant nephrologists and/or renal nurses. Twenty-eight (45%) units had staff whose time was specifically allocated for patients with CKD5 who were on a CKM pathway; "larger" units were more likely to have such staff (15 of 24 versus eight of 23). Sixteen units had renal nurses whose time was specifically allocated for such patients; a median FTE of these 16 units was 0.9 (IQR, 0.5–1.0). Twelve units responded that consultant nephrologists had allocated time for CKM patients with a median FTE of 0.2 (IQR, 0.1–0.2). Nine units had predialysis education providers or dietitians whose time was allocated for CKM patients. These units had median FTEs of 0.4 (IQR, 0.18–1.0) and 0.2 (IQR, 0.1–0.35), respectively.

Twenty-three units (35%) had a written guideline on how to manage CKM patients. Fifteen units (23%) reported having clinics exclusively for these patients; in the other units, 22 most commonly saw them in predialysis clinics, 11 in general nephrology clinics, seven in the patient’s home (three by renal staff and four by a general practitioner/community team), and nine in mixed settings. The availability of dedicated CKM clinics was closely related to whether units had staff primarily responsible for CKM (P=0.001); however, 64% of the units that had staff responsible for CKM practiced CKM without dedicated clinics.

Half of the units (33 of 66) provided renal staff with formal training or education regarding CKM. In the 21 units without such training, 11 unit respondents reported lack of time and eight lack of funding as reasons for not doing so. Five reported that staff did not need formal training because CKM was an ingrained culture in the unit.

CKM programs offered a variety of services to patients. All units assessed and managed symptoms and provided erythropoietin and iron therapy. Almost all units provided dietary advice (64 of 65 [99%]) and prescribed medication for uremic symptoms (63 of 65 [97%]) (Figure 1). Most but not all units reported providing advance care planning, which in the UK refers to a formal process for considering end-of-life care.

Figure 1.
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Figure 1.

Percentages of renal units providing different components of conservative kidney management to patients (n=65). The Gold Standards Framework in end of life care is a framework to enable generalist frontline staff to provide a gold standard of care for people nearing the end of life.

Only a minority of units (10 of 65 [15%]) had funding dedicated to providing CKM; in seven units this was from the National Health Service (NHS), in one unit it was from non-NHS sources, and two had funding from both sources. Only five units reported the amount; the median was £40,000 (IQR, £15,203–£85,629.50) in the 2011–2012 financial year. Funding was associated with the CKM population size (larger versus smaller) (P<0.01) and with dedicated staff time for CKM (P=0.002); however, 68% of units with dedicated staff had no dedicated CKM funding.

The larger CKM units had more prevalent dialysis patients age 75 and older (median, 161; IQR, 118–201) than the smaller ones (median, 54; IQR, 43–122), and those with missing CKM data were intermediate in size (median, 95; IQR, 60–173). Intercountry comparisons were difficult because of the smaller number of respondents in countries outside of England.

Decision-Making

Most units (56 of 65 [86%]) reported that they discussed the option of CKM with all patients with CKD5 who were 75 years of age and older. Similar criteria were used to assess suitability for CKM for a patient, the foremost being patients’ preference for CKM (100%) (Figure 2).

Figure 2.
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Figure 2.

Distribution across renal units of responses to the question: “Which of the following factors are likely to influence staff when contemplating the suitability of conservative care for a patient? Please indicate how strongly each would influence a decision to discuss conservative care with a patient/carer. Please answer on behalf of all staff members.” Values are expressed as percentage of units (n=65) CKM, conservative kidney management. *“Would I be surprised if this patient died in the next year?” †n=64 because of missing responses.

The option of CKM was most commonly first raised with patients when they were referred to the predialysis clinic (37 of 65 [57%]). In 15 units (23%) the option was raised when a patient’s eGFR reached a certain level (median, 20 ml/min per 1.73 m2; IQR, 19.0–20.0 ml/min per 1.73 m2) and in six (9%) at a specific time before the anticipated start of dialysis (median, 9 months; IQR, 5.3–12.0 months). Most units (54 of 65 [83%]) used decision aids when discussing the option of CKM with a patient. Booklets and handouts from national organizations (44 of 54) and those written by local renal unit staff (33 of 54) were commonly used. About half of the units (22 fo 54) used DVDs from national organizations. Sixteen units used the NHS Right Care Patient Decision Aid (22). Once patients decided to have CKM, all units reported that they subsequently reviewed their decision, mostly at clinic visits.

Family and carers were actively involved in decision-making about CKM. Most units (62 of 65 [95%]) encouraged family and carers to attend clinics with patients, and they were also involved when the CKM decision was revisited with patients (50 of 65 [77%]). All responding units had patients who had changed their mind after deciding not to have dialysis, although this could not be quantified.

Liaison with Primary and Palliative Care

All units reported that they worked collaboratively with primary and palliative care teams. Most units (57 of 65 [88%]) provided general practitioners and their practice team with information and advice on the treatment of patients with CKD5 receiving CKM. All worked with palliative care services to provide care for CKM patients approaching the end of life: within the hospital (59 of 65 [91%]), at a local hospice (51 of 65 [79%]), in the community (55 of 65 [85%]), and from the primary care team (58 of 65 [89%]). Almost all units (62 of 65 [95%]) used more than one service; 38 of 65 units (58%) worked with all the above. More than half of units (36 of 65 [55%]) had a written guideline for renal end-of-life care, and 11 (17%) had one in preparation.

More than half of the units (42 65 [65%]) provided palliative care specialists with training or advice regarding the management of renal patients. Most units (57 of 64 [89%]) had trained their own staff in palliative/end-of-life care for renal patients, although in 39 of those 57 units it was only a small proportion of such staff.

Future Development

The factors reported to be most important to improve the provision of CKM in future were providing renal staff and general practitioners with more CKM training, and increasing communication and involvement with general practitioners, community, and palliative care teams (Figure 3). Eighty percent of unit respondents agreed that having better evidence of the comparative outcomes between CKM and dialysis would help improve the provision of conservative care.

Figure 3.
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Figure 3.

Distribution across renal units of responses to the question: “Which factors do you think could help improve the provision of conservative care in your unit? Please indicate how strongly you agree or disagree with each of the following.” Values are expressed as percentage of units (n=64). †n=63; ‡n=62 because of missing responses. ACP, advance care planning; CKM, conservative kidney management; GP, general practitioner.

The most common areas for planned development were providing renal staff members with more CKM training, and providing better end-of-life care by implementing advance care planning (Figure 4). Increasing the number of staff dedicated to CKM, setting up dedicated CKM clinics, and obtaining funding were not commonly cited.

Figure 4.
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Figure 4.

Distribution across renal units of responses to the question: “What, if any, of the following changes are planned in your unit regarding the provision of conservative care? Please tick all that apply.” Values are expressed as percentage of units (n=63). ACP, advance care planning; CKM, conservative kidney management; GP, general practitioner.

CKM Research

Sixty unit respondents (92%) would consider entering a patient age 75 years and older with CKD5 into a prospective observational study of CKM versus dialysis; 28 of those reported willingness to participate in such a study. Forty-two unit respondents (65%) considered it appropriate to enter patients into a randomized trial comparing CKM versus dialysis; 18 of those reported being definitely willing to participate in such a trial.

Discussion

To our knowledge, this is the first national survey to explore the practice patterns of renal units regarding the care of older adults who choose not to have dialysis. The study has demonstrated the widespread acceptance of a conservative pathway by UK nephrology services. CKM practice patterns varied markedly across units; some showed considerable investment in staff time and consequent processes, such as dedicated clinics, guidelines, and staff training programs. However, the CKM decision-making process was similar across units: most reported that they undertook shared informed decision-making with patients with CKD5 age 75 years and older by presenting treatment options, including CKM, and decision aids were widely used.

Many units did not report the numbers of patients receiving CKM, indicating that these data were not captured prospectively. In units that did report the number of patients designated as receiving CKM, the wide variation indicates lack of clarity regarding CKM patients, reinforcing the need for a more precise definition of CKM. It may be that two designations are needed to capture key points on the pathway: (1) a decision to opt for conservative care and not to prepare for dialysis and (2) a decision to have conservative care and not to start dialysis despite uremic symptoms.

The number of patients receiving CKM was related to the number of patients age 75 and older receiving RRT and was relatively small in comparison. The units that did not report CKM numbers were intermediate in terms of the number of RRT patients age 75 and older, suggesting no major bias in response regarding the size of unit.

Many renal units first raised the option of CKM with patients when they were referred to the predialysis clinics or when their GFR was about 20 ml/min per 1.73 m2. This compares with a study conducted by Morton et al. (23), in which 84% of Australian patients received information about treatment options when their eGFR was <15 ml/min per 1.73 m2. Only a minority of units used predicted time to dialysis rather than eGFR to decide when to discuss the CKM option with a patient. Many patients with CKD have a nonlinear eGFR trajectory or a prolonged period of nonprogression in contrast to the traditional notion of steady GFR progression over time (24). This suggests that careful assessment of kidney disease progression is needed to decide when to discuss CKM with patients.

The survey has identified the need for more education and training of renal professionals in delivering a CKM pathway. Because of the very specific challenges entailed, renal-specific training may be useful, such as the training in advanced communication skills tailored to advanced kidney disease developed by Bristowe et al. (25).

Most units reported having no dedicated funding for CKM, and although many units thought that more funding could help develop CKM, only a minority were planning to apply for funding. In England, preparation for RRT (or "renal assessment") and RRT per se are commissioned as specialist services, and there are specific "payment by results" tariffs. However, while CKM is mentioned within the renal assessment pathway, it is commissioned locally on the basis of the rationale that CKM does not require specialist RRT infrastructure. The lack of a tariff for CKM care was seen as a barrier to developing these services, especially considering that CKM care can last up to a few years because it is not only end-of-life care.

All units reported working collaboratively with primary care. Many units felt that increasing communication and involvement with general practitioners, community, and palliative care teams was very important to improve CKM. Such teams, including social care professionals, have a central coordinating role in the end-of-life phase and need renal-specific training.

In the UK, specialist palliative care was previously restricted to patients with malignant disease (20). However, recent data (26) demonstrate that specialist palliative care services accepted more referrals of patients with ESRD. Our survey has shown that all units now work with specialist palliative care service for CKM patients approaching the end of life, and 79% of units worked with palliative care services from local hospices. Similarly, over half have a written renal end-of-life care guideline compared with 20% 10 years ago (20). Almost all units have staff who have been trained in palliative end-of-life care for renal patients. The variation in the proportion of such staff may relate to a lack of resources or a higher priority being given to involving palliative care specialists rather than developing the skills of renal staff.

Although we achieved an excellent response rate across all parts of the UK and used a detailed structured questionnaire, some limitations need to be addressed. The survey responses were self-reported by renal staff, and we could not check their validity. Some of these data were necessarily estimates and so should be regarded with caution, such as the number of CKM patients age 75 years and older and the number who were symptomatic. This survey focused on CKM patients age 75 years and older, but patients younger than 75 years may benefit from CKM (11). While we examined whether some selected factors were associated with the use of certain practices regarding CKM, we could not determine causal relationships from the cross-sectional design. Our categorization of units into larger and smaller categories was somewhat arbitrary. Furthermore, most questions in the survey were multiple-choice questions that asked respondents to select the best possible answer out of the choices from a list. This may have limited their responses, although a selection of "other" was provided.

On the basis of this survey we conclude that the following would facilitate the development and assessment of CKM services: (1) an agreed-upon terminology and definition of CKM; (2) identification and provision of funding for CKM; (3) education and training of renal staff in advanced communication skills and in how to discuss and address palliative and supportive care needs, including end-of-life care; and (4) better communication and information-sharing with primary and palliative care teams and their training in the renal-specific elements of CKM care.

We have identified support from renal clinicians for further research into the benefits and costs of CKM compared with dialysis to inform decision-making by staff, patients, and their families. While widely supported, an observational study would be hampered by confounding caused by nonrandom treatment allocation and by the imprecision of the timing of the start of the CKM pathway. A clinical trial in which patients are allocated to CKM or dialysis by random allocation would overcome many of these problems but would pose substantial ethical issues. Nonetheless, many respondents in this UK survey expressed support for such a trial. Further study of the feasibility of such a randomized clinical trial is warranted.

Disclosures

None.

Acknowledgments

We would like to thank all clinical directors of the renal units and the additional staff members who responded to the survey. The results presented here are part of a larger study, CKMAPPS (Conservative Kidney Management Assessment of Practice Patterns Study). CKMAPPS was funded by the NIHR Health Services Research (HSR) Programme (project number 09/2000/36) and will be published in full in the Health Services and Delivery Research Journal. Further information available at: http://www.nets.nihr.ac.uk/projects/hsdr/09200036.

Footnotes

  • Published online ahead of print. Publication date available at www.cjasn.org.

  • This article contains supplemental material online at http://cjasn.asnjournals.org/lookup/suppl/doi:10.2215/CJN.05000514/-/DCSupplemental.

  • Received May 21, 2014.
  • Accepted September 26, 2014.
  • Copyright © 2015 by the American Society of Nephrology

References

  1. ↵
    1. Murtagh FE,
    2. Marsh JE,
    3. Donohoe P,
    4. Ekbal NJ,
    5. Sheerin NS,
    6. Harris FE
    : Dialysis or not? A comparative survival study of patients over 75 years with chronic kidney disease stage 5. Nephrol Dial Transplant 22: 1955–1962, 2007pmid:17412702
    OpenUrlCrossRefPubMed
  2. ↵
    1. Smith C,
    2. Da Silva-Gane M,
    3. Chandna S,
    4. Warwicker P,
    5. Greenwood R,
    6. Farrington K
    : Choosing not to dialyse: evaluation of planned non-dialytic management in a cohort of patients with end-stage renal failure. Nephron Clin Pract 95: c40–c46, 2003pmid:14610329
    OpenUrlCrossRefPubMed
  3. ↵
    1. Tamura MJ,
    2. Covinsky KE,
    3. Chertow GM,
    4. Yaffe K,
    5. Landefeld CS
    , McCulloch CE: Functional status of elderly adults before and after initiation of dialysis. N Engl J Med 361: 1539–1547, 2009
    OpenUrlCrossRefPubMed
  4. ↵
    1. Jassal SV,
    2. Watson D
    : Dialysis in late life: benefit or burden. Clin J Am Soc Nephrol 4: 2008–2012, 2009pmid:19965545
    OpenUrlAbstract/FREE Full Text
    1. Jassal SV,
    2. Chiu E,
    3. Hladunewich M
    : Loss of independence in patients starting dialysis at 80 years of age or older. N Engl J Med 361: 1612–1613, 2009pmid:19828543
    OpenUrlCrossRefPubMed
  5. ↵
    1. Chandna SM,
    2. Da Silva-Gane M,
    3. Marshall C,
    4. Warwicker P,
    5. Greenwood RN,
    6. Farrington K
    : Survival of elderly patients with stage 5 CKD: comparison of conservative management and renal replacement therapy. Nephrol Dial Transplant 26: 1608–1614, 2011pmid:21098012
    OpenUrlCrossRefPubMed
    1. Carson RC,
    2. Juszczak M,
    3. Davenport A,
    4. Burns A
    : Is maximum conservative management an equivalent treatment option to dialysis for elderly patients with significant comorbid disease? Clin J Am Soc Nephrol 4: 1611–1619, 2009pmid:19808244
    OpenUrlAbstract/FREE Full Text
    1. Da Silva-Gane M,
    2. Wellsted D,
    3. Greenshields H,
    4. Norton S,
    5. Chandna SM,
    6. Farrington K
    : Quality of life and survival in patients with advanced kidney failure managed conservatively or by dialysis. Clin J Am Soc Nephrol 7: 2002–2009, 2012pmid:22956262
    OpenUrlAbstract/FREE Full Text
  6. ↵
    1. Wong CF,
    2. McCarthy M,
    3. Howse ML,
    4. Williams PS
    : Factors affecting survival in advanced chronic kidney disease patients who choose not to receive dialysis. Ren Fail 29: 653–659, 2007pmid:17763158
    OpenUrlCrossRefPubMed
  7. ↵
    1. Hussain JA,
    2. Mooney A,
    3. Russon L
    : Comparison of survival analysis and palliative care involvement in patients aged over 70 years choosing conservative management or renal replacement therapy in advanced chronic kidney disease. Palliat Med 27: 829–839, 2013pmid:23652841
    OpenUrlCrossRefPubMed
  8. ↵
    1. Morton RL,
    2. Turner RM,
    3. Howard K,
    4. Snelling P,
    5. Webster AC
    : Patients who plan for conservative care rather than dialysis: a national observational study in Australia. Am J Kidney Dis 59: 419–427, 2012pmid:22014401
    OpenUrlCrossRefPubMed
  9. ↵
    1. Morton RL,
    2. Snelling P,
    3. Webster AC,
    4. Rose J,
    5. Masterson R,
    6. Johnson DW,
    7. Howard K
    : Factors influencing patient choice of dialysis versus conservative care to treat end-stage kidney disease. CMAJ 184: E277–E283, 2012pmid:22311947
    OpenUrlAbstract/FREE Full Text
  10. ↵
    1. Stojceva-Taneva O,
    2. Cala S,
    3. Stel VS,
    4. Tomson C,
    5. Jager KJ
    1. van de Luijtgaarden MW,
    2. Noordzij M,
    3. van Biesen W,
    4. Couchoud C,
    5. Cancarini G,
    6. Bos WJ,
    7. Dekker FW,
    8. Gorriz JL,
    9. Iatrou C,
    10. Wanner C,
    11. Finne P
    ,Stojceva-Taneva O, Cala S, Stel VS, Tomson C, Jager KJ: Conservative care in Europe–nephrologists' experience with the decision not to start renal replacement therapy. Nephrol Dial Transplant 28: 2604–2612, 2013
    1. De Biase V,
    2. Tobaldini O,
    3. Boaretti C,
    4. Abaterusso C,
    5. Pertica N,
    6. Loschiavo C,
    7. Trabucco G,
    8. Lupo A,
    9. Gambaro G
    : Prolonged conservative treatment for frail elderly patients with end-stage renal disease: The Verona experience. Nephrol Dial Transplant 23: 1313–1317, 2008pmid:18029376
    OpenUrlCrossRefPubMed
  11. ↵
    1. Joly D,
    2. Anglicheau D,
    3. Alberti C,
    4. Nguyen A-T,
    5. Touam M,
    6. Grünfeld J-P,
    7. Jungers P
    : Octogenarians reaching end-stage renal disease: Cohort study of decision-making and clinical outcomes. J Am Soc Nephrol 14: 1012–1021, 2003pmid:12660336
    OpenUrlAbstract/FREE Full Text
  12. ↵
    1. Seah AS,
    2. Tan F,
    3. Srinivas S,
    4. Wu HY,
    5. Griva K
    : Opting out of dialysis - Exploring patients’ decisions to forego dialysis in favour of conservative non-dialytic management for end-stage renal disease. Health Expect : 2013pmid:23647805
    OpenUrlPubMed
  13. ↵
    1. Shum CK,
    2. Tam KF,
    3. Chak WL,
    4. Chan TC,
    5. Mak YF,
    6. Chau KF
    : Outcomes in older adults with stage 5 chronic kidney disease: comparison of peritoneal dialysis and conservative management. J Gerontol A Biol Sci Med Sci 69: 308–314, 2014pmid:23913933
    OpenUrlCrossRefPubMed
  14. ↵
    1. Teo BW,
    2. Ma V,
    3. Xu H,
    4. Li J,
    5. Lee EJ,
    6. Nephrology Clinical Research Group
    : Profile of hospitalisation and death in the first year after diagnosis of end-stage renal disease in a multi-ethnic Asian population. Ann Acad Med Singapore 39: 79–87, 2010pmid:20237727
    OpenUrlPubMed
  15. ↵
    1. Alston H
    : Conservative care for end-stage kidney disease: Joint medical conference with the Renal Association, British Geriatrics Society and Association for Palliative Medicine. Clin Med 13: 383–386, 2013pmid:23908510
    OpenUrlAbstract/FREE Full Text
  16. ↵
    1. Gunda S,
    2. Thomas M,
    3. Smith S
    : National survey of palliative care in end-stage renal disease in the UK. Nephrol Dial Transplant 20: 392–395, 2005pmid:15618241
    OpenUrlCrossRefPubMed
  17. ↵
    1. UK Renal Registry
    : UK Renal Registry 16th Annual Report, Bristol, UK, UK Renal Registry, 2013
  18. ↵
    Right Care NHS: Kidney failure treatment options—shared decision making. Available at http://sdm.rightcare.nhs.uk/pda/established-kidney-failure/. Accessed April 11, 2014
  19. ↵
    1. Morton RL,
    2. Howard K,
    3. Webster AC,
    4. Snelling P
    : Patient INformation about Options for Treatment (PINOT): A prospective national study of information given to incident CKD Stage 5 patients. Nephrol Dial Transplant 26: 1266–1274, 2011pmid:20819955
    OpenUrlCrossRefPubMed
  20. ↵
    1. Li L,
    2. Astor BC,
    3. Lewis J,
    4. Hu B,
    5. Appel LJ,
    6. Lipkowitz MS,
    7. Toto RD,
    8. Wang X,
    9. Wright JT Jr.,
    10. Greene TH
    : Longitudinal progression trajectory of GFR among patients with CKD. Am J Kidney Dis 59: 504–512, 2012pmid:22284441
    OpenUrlCrossRefPubMed
  21. ↵
    1. Bristowe K,
    2. Shepherd K,
    3. Bryan L,
    4. Brown H,
    5. Carey I,
    6. Matthews B,
    7. O'Donoghue D,
    8. Vinen K,
    9. Murtagh FE
    : The development and piloting of the REnal specific Advanced Communication Training (REACT) programme to improve Advance Care Planning for renal patients. Palliat Med 28: 360–366, 2014pmid:24201135
    OpenUrlCrossRefPubMed
  22. ↵
    1. Hobson K,
    2. Gomm S,
    3. Murtagh F,
    4. Caress AL
    : National survey of the current provision of specialist palliative care services for patients with end-stage renal disease. Nephrol Dial Transplant 26: 1275–1281, 2011pmid:20813768
    OpenUrlCrossRefPubMed
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Clinical Journal of the American Society of Nephrology: 10 (1)
Clinical Journal of the American Society of Nephrology
Vol. 10, Issue 1
January 07, 2015
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Conservative Care for ESRD in the United Kingdom: A National Survey
Ikumi Okamoto, Sarah Tonkin-Crine, Hugh Rayner, Fliss E.M. Murtagh, Ken Farrington, Fergus Caskey, Charles Tomson, Fiona Loud, Roger Greenwood, Donal J. O’Donoghue, Paul Roderick
CJASN Jan 2015, 10 (1) 120-126; DOI: 10.2215/CJN.05000514

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Conservative Care for ESRD in the United Kingdom: A National Survey
Ikumi Okamoto, Sarah Tonkin-Crine, Hugh Rayner, Fliss E.M. Murtagh, Ken Farrington, Fergus Caskey, Charles Tomson, Fiona Loud, Roger Greenwood, Donal J. O’Donoghue, Paul Roderick
CJASN Jan 2015, 10 (1) 120-126; DOI: 10.2215/CJN.05000514
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Health Services Research

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Cited By...

  • Hospice care access inequalities: a systematic review and narrative synthesis
  • Provider Knowledge, Attitudes, and Practices Surrounding Conservative Management for Patients with Advanced CKD
  • The Providers Role in Conservative Care and Advance Care Planning for Patients with ESRD
  • Conservative care of the patient with end-stage renal disease
  • GPs views on managing advanced chronic kidney disease in primary care: a qualitative study
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