#NephMadness 2020: Koncicki’s Pick for the Ethics Region – Dialysis for Patients at the End-of-Life
Holly Koncicki completed her medicine residency training at Mount Sinai Hospital, followed by completion of an integrated fellowship in nephrology and palliative medicine. She is currently appointed as Assistant Professor at the Icahn School of Medicine at Mount Sinai. Dr. Koncicki is working closely with the fellowship leadership at Mount Sinai in shaping the curriculum for the integrated nephrology and palliative care fellowship.
Competitors for theEthics Region：
Policy-Driven Outcomes for DialysisvsPatient-Driven Choice for Dialysis
End-of-Life Care for Patients on DialysisvsDialysis for Patients at End-of-Life
这 ”生命尽头患者的透析” team has the potential to provide quite the upset in this year’s NephMadness tournament. No one is expecting this quiet team to go all the way. Who is this team? Let’s take a closer look.
Here’s what they know: The growth of maintenance dialysis patients over the age of 75 has doubled in recent years. Adjusted mortality for patients on dialysis is nearly twice that of cancer and more than twice that of patients with heart failure or stroke. Five-year survival of patients on hemodialysis is estimated to be about 42%. A recent study of 400 incident dialysis patients over the age of 65 estimated 1-year mortality to be 54.5%.
In terms of what our patients value, increased survival is actually not at the top of their list – other metrics such as independence take the top pick. Here is the big question: Is there another way to deliver dialysis at the end-of-life? And should dialysis treatments differ for patients with an expected prognosis of a year or less? This team thinks so.
Not many other teams can compare to their talent of eliciting patient goals and preferences, and this is where the team may run away with the game. Here’s their strategy: First, they discuss prognosis and goals of care. This is a time-consuming process but the reward is tremendous. Eliciting what is most important to the patient will help the provider make recommendations on how to align patient-centered metrics with their dialysis treatments, rather than focusing on standard dialysis care metrics.
Then this team really pulls out a playbook that many have never seen before. As they try to focus on patient-centered metrics, such as symptom management and health-related quality-of-life, they may do things like accepting a central venous catheter in lieu of pursuing an AVG or AVF in the patient (stunned silence from the crowd). They may liberalize a patient’s diet, permitting hyperphosphatemia and limit medications to allow for hyperparathyroidism (crowd gasps!). They may focus more on optimization of volume status and with that, they may decrease treatments to just twice per week, accepting lower clearances (opposing coach throws hands up in the air).
– Guest Post written byHolly Koncicki@hollymariemd
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