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Estimating prognosis


The authors of the paper are Dr. Stephen M. Wittenberg from the Department of Medicine and Dr. Lewis M. Cohen from the Department of Psychiatry - both are from Baystate Medical Centre, Springfield, Massachusetts, U.S.A. The authors draw our attention to American statistics, which indicate that 85,000 patients with end stage renal disease (ESRD) die every year, yet nephrologists commonly avoid discussions around prognosis. The authors of the study pointed out that having ESRD patients assess their own health condition might also be an independent predictor of death because these patients have insight into their quality of life, self-management behaviours and treatment compliance/non-compliance.

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									Research review

Copyright 2010 Canadian Association of Nephrology Nurses and Technologists

                                                  these matters” (p. 165). In another            help patients and their families make
 Wittenberg, S.M., & Cohen, L.M.                  survey undertaken by Fine, Fontaine,           informed decisions about their care and
       (2009). Estimating prognosis in            Kraushar, and Rich (2005) of 100               future goals. With the lack of training in
       end-stage renal disease. Progress in       patients with chronic kidney disease, the      communication in end-of-life care
       Palliative Care, 17(4), 165–169.
                                                  researchers found that 97% of                  within the nephrology fellowship
                                                  respondents         wanted      prognostic     programs, it is not shocking that these
Reviewed by Kalli Stilos, RN, MScN,               information and more than 50% of the           discussions do not take place between
CHPCN(C), Advanced Practice Nurse,                respondents stated they needed to know         physicians, patients and their families.
Palliative Care Consult Team,                     their prognosis on dialysis. Large             Giving bad news to patients and their
Sunnybrook Health Science Centre,                 percentages wanted this information so         families in a patient-centred and
Toronto, ON                                       they were “better prepared to accept           culturally sensitive approach is not
   The author’s purpose for this review           what happens in the future” (p. 165) and       common to physicians’ practice.
article was to explore estimating                 believed that their nephrologists should       Discussions like these need time, a quiet,
prognosis within the context of end stage         volunteer that information and that they       private and comfortable place for the
renal disease (ESRD); to present factors          should not have to be prompted for it.         patient and their loved ones. To address
that prevent physicians from discussing           Additional studies are cited to support        this issue, the nephrology community is
this issue; and to review existing methods        this point.                                    starting to include the topic of
used for formulating a prognosis. The                 The Renal Physicians Association and       communication in their curriculum.
authors of the paper are Dr. Stephen M.           American Society of Nephrology clinical           A concern for nephrologists is that by
Wittenberg from the Department of                 practice guidelines (2000) on initiation       having discussions around prognosis, it
Medicine and Dr. Lewis M. Cohen from              and withdrawal of dialysis suggest the         may demoralize patients and their loved
the Department of Psychiatry—both are             issue of prognosis be discussed with           ones, causing them psychological
from Baystate Medical Centre,                     patients, yet it is an area nephrologists      distress. This review article references
Springfield, Massachusetts, U.S.A.                 fail to articulate. Reinforcing the need to    several studies that support open,
   The authors draw our attention to              have these discussions is the statistic that   ongoing dialogue about poor prognosis
American statistics, which indicate that          “one- and five-year mortality rates in          as a key factor in strengthening the
85,000 patients with end stage renal              ESRD are 25% and 60% respectively—             patient-physician relationship and also
disease (ESRD) die every year, yet                considerably higher than that of most          to enhance patients’ hope by shaping
nephrologists        commonly        avoid        cancers” (p. 168). It has been                 future decisions that are in line with
discussions around prognosis. Research            recommended that further research be           their goals and values.
has found that dialysis patients want to          performed on estimating the prognosis of          Another reason why nephrologists
know this pertinent information. In               renal patients.                                forgo discussions about prognosis is the
2008, the National Kidney Foundation                  Many factors hinder end-of-life            lack of prognostic tools available that are
(Weiner, 2008) conducted an “online               discussions. The review article focuses on     generalizable, precise and useful. The
survey of 182 dialysis patients and found         three that are largely responsible for non-    Surprise Question (SQ) is an instrument
that: a) 5
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