Original Article
Effects of an intervention to improve communication about end-of-life care among African Americans with chronic kidney disease

https://doi.org/10.1016/j.apnr.2008.05.002Get rights and content

Abstract

The prevalence of and mortality from chronic kidney disease (CKD) are high among African Americans. Interventions to improve knowledge of the likely illness course and the benefits and risks of life-sustaining treatment at the end-of-life are needed for African Americans with CKD and their surrogate decision makers. Nineteen African Americans with stage 5 CKD and their surrogates were randomized to either patient-centered advance care planning (PC-ACP) or usual care. PC-ACP dyads showed greater improvement in congruence in end-of-life treatment preferences (p < .05) and higher perceived quality of communication (p < .05) than do control dyads, but the two groups did not differ on other primary outcomes or acceptability measures, such as perceptions of cultural appropriateness. At posttest, 80% of patients in the intervention group reported that they would choose to continue all life-sustaining treatments in a situation of a low chance of survival, whereas 28.6% of patients in the control group reported that they would make that choice. At posttest, 90% of patients in the intervention group reported that they would choose to undergo cardiopulmonary resuscitation even if the chance of surviving the attempt would be low, whereas 57% of patients in the control group reported that they would make that choice. PC-ACP can be effective in improving patient and surrogate congruence in end-of-life treatment preferences. However, the results suggest a need for further improvements in the intervention to enhance cultural appropriateness for African Americans with CKD.

Section snippets

Sample and design

Dialysis clinic patients were eligible to join the study if they (a) had been receiving either center hemodialysis or home peritoneal dialysis for at least 3 months, (b) were over the age of 18, and (c) had a surrogate decision maker who was over the age of 18. Thirty-four patients were assessed for eligibility and approached with study information by a social worker at the clinic. Nineteen patient and surrogate dyads who joined the study as pairs were stratified by type of dialysis

Sociodemographic and clinical characteristics of the sample

Most of the patients were men (n = 10, 58.8%), single (n = 11, 64.7%), and had completed a high school education or higher (n = 15, 88.2%). Their average age is 52.82 (SD = 15.50) years. Just less than half of the patients (n = 8, 47.1%) reported their annual household incomes to be <$11,000 and stated that Medicare was their primary health insurance. Most of the surrogates were women (n = 15, 88.2%), single (n = 11, 64.7%), and had completed a high school education or higher (n = 15, 88.2%).

Discussion

Among the primary outcomes, only dyads' congruence improved significantly after PC-ACP. The hypotheses that PC-ACP would decrease patients' decisional conflict and increase surrogates' decision-making confidence were not supported. We observed a shift in preferences for life-sustaining treatment from baseline to 1 week follow-up among seven (70%) patients in the intervention group. However, the direction of the shift was counter to our expectation. The shift occurred either from “stop all

Acknowledgment

This study was supported by the University of Pittsburgh Central Research Development Fund and was conducted at the University of Pittsburgh School of Nursing. The authors thank Linda Briggs, MS, MA, RN, and Bernard Hammes, PhD, for their contributions to the project: interventionist training and the consultations in implementing the intervention. The authors also thank Iris Hayes, MSW, and the staff at the Dialysis Clinic Inc.-Oakland for their effort in participant recruitment.

References (35)

  • CalvinA.O.

    Haemodialysis patients and end-of-life decisions: A theory of personal preservation

    Journal of Advanced Nursing

    (2004)
  • ChambersE. et al.

    Supportive and palliative care for renal patients

    (2004)
  • CohenL.M. et al.

    Practical considerations in dialysis withdrawal: “To have that option is a blessing”

    JAMA

    (2003)
  • CohenL.M. et al.

    Renal palliative care

    Journal of Palliative Medicine

    (2006)
  • CurtisJ.R. et al.

    The quality of patient–doctor communication about end-of-life care: A study of patients with advanced AIDS and their primary care clinicians

    AIDS

    (1999)
  • Dilworth-AndersonP. et al.

    Recruitment and retention strategies for longitudinal African American caregiving research: The Family Caregiving Project

    Journal of Aging and Health

    (2004)
  • DonovanH.S. et al.

    A representational approach to patient education

    Journal of Nursing Scholarship

    (2001)
  • Cited by (62)

    • Interventions Guiding Advance Care Planning Conversations: A Systematic Review

      2019, Journal of the American Medical Directors Association
    View all citing articles on Scopus
    1

    Senior author: Tel.: +1 608 263 5277; e-mail address: [email protected] (S.E. Ward).

    View full text