Article Title

Providing an Upstream Discussion in the Ambulatory Setting to Assist Chronic Kidney Disease Patients Considering Dialysis

Publication Date



advance care planning, shared decision-making


Background/Aims: Extensive discussion with renal patients about treatment intensity is not systematically integrated into their care. These discussions are often time-consuming, involve family, and require multiple discussions. The discussion often takes place during an acute hospitalization. We conducted a “test of change” pilot to assess the utility of providing an upstream discussion in the ambulatory setting as an additional nephrology consult to assist renal patients with chronic kidney disease considering treatment choice. We believed our pilot would show this additional nephrology consult would help our chronic kidney disease patients to be more informed about choosing or not choosing dialysis, and would also assist us in resource stewardship.

Methods: We randomly assigned nephrology patients at Kaiser Permanente South Bay Medical Center with stage 4 or 5 chronic kidney disease who had not yet begun dialysis. The test group received the additional nephrology consult and was seen by an interdisciplinary team comprised of a nephrologist, a social worker and a clinical ethicist.

Results: Those who received the additional nephrology consult experienced help in forming a treatment plan, felt well-understood, and had the opportunity to thoroughly discuss questions. The control group that did not receive the additional nephrology consult had a 26% increased probability of beginning dialysis, had a statistical increase for dialysis and clinic visits (P<0.10 and P<0.05), and were more likely to be admitted to the hospital (control 0.5 vs. test 0.2 admissions per patient), spend more days hospitalized (control 2.8 vs. test 0.5 bed days per patient), and be seen in the emergency room (control 0.73 vs. test 0.66 visits per patient) and clinic (control 6.6 vs. test 3.6 visits per patient).

Discussion: We attempted to review the utility of providing an upstream discussion in the ambulatory setting for renal patients considering treatment plan decision-making. Interdisciplinary consultations in the ambulatory setting allows us to begin a helpful conversation that can include helping patients and families better understand the possibilities of medicine, patients’ treatment goals, and lived values from the patients’ context.




March 30th, 2015


April 28th, 2015