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International Council of Nurses Congress – Using Social Media to Engage with Nurses

21 May, 17 | by josmith

Roberta Heale (@robertaheale) & Joanna Smith (@josmith175) Associate Editors, EBN

We are presenting how Evidence Based Nursing (EBN) is using social media to engage with nurses at the International Council of Nurses (ICN) Congress, being help at the end of May 2017 in Barcelona, Spain. Nurses across the globe will be exploring nurses’ roles in leading the transformation of care, & is an opportunity for nurses to build networks, share & disseminate nursing practices across specialties, cultures & countries, http://www.icnbarcelona2017.com/

The ICN ams to

Demonstrate & advance the nursing contribution to informed & sustainable health policies;

Support nursing’s contribution to evidence-based healthcare & encourage problem-solving approaches to health priority needs:

Provide opportunities for an in-depth exchange of experience & expertise within & beyond the international nursing community.

We are excited to be representing the work of EBN at the ICN Congress, and networking with peers. Although the journal’s main purpose is to publish expert commentaries on current research that is relevant to nursing, over the last few years EBN editors have implemented a social media strategy to increase engagement with our readers, their access to evidence for practice & awareness of important health issues. We will be sharing our social media strategies that include:

  • Posting regularly on our Facebook @BMJNursing & Twitter account @EBNursingBMJ;
  • Hosting fortnightly Twitter Chats which are linked to a new Opinions article series relating to discussing participants’ key messages during the Twitter chat;
  • Publishing weekly blogs (http://blogs.bmj.com/ebn/);
  • Recording podcasts with authors of commentaries to expand & debate in more depth issues raised in the commentary.

Caring for agitated patients

14 May, 17 | by josmith

This week’s EBN Twitter Chat on Wednesday 17th May 2017 between 8-9 pm (UK time) will focus on caring for agitated patients and is being hosted by Angela Teece (A.M.Teece@leeds.ac.uk), Trainee Lecturer in
Adult Nursing, University of Leeds @AngelaTeece and Sam Freeman (samantha.freeman@manchester.ac.uk) Lecturer in Adult Nursing, University of Manchester Twitter @Sam_Freeman.

Participating in the Twitter chat requires a Twitter account; if you do not have one you can create an account at www.twitter.com. Once you have an account, contributing is straightforward. You can follow the discussion by searching links to #ebnjc, or contribute by creating and sending a tweet (tweets are text messages limited to 140 characters) to adding #ebnjc (the EBN Twitter chat hash tag) to your tweet, this allows everyone taking part to view your tweets.

What is an agitated patient? It could be a patient who is restless, kicking their legs over the bed rails or refusing to lie still. Or maybe it is the patient who repeatedly flicks off the saturation probe, causing the machine to alarm. Or do you see an agitated patient as one whose behaviour risks serious harm to themselves or you as their nurse? The underlying causes for admission to critical care areas is vast. The commonality is the individual is experiencing illness so severe they cannot be managed elsewhere and require drastic intervention. The admission can be traumatic and potentially life altering event. Delirium, which is common amongst intensive care (ICU) patients, can present as extreme agitation, and lead to poor compliance with essential therapies and rehabilitation (Collinsworth et al., 2016). Awakening from sedation or withdrawal from alcohol and drugs may also lead to agitated behaviour.

Management of agitation is dependent upon the severity of the problem and the clinical area where the patient is being nursed. A restless patient might require extra supervision, particularly at night when staffing and patient visibility is poor. Such patients benefit from regular reorientation. In ICU, agitated patients are at risk of removing essential devices, such as central venous catheters, potentially causing serious harm or death (Mion, 2008). In more severe cases of agitation the management approach may be either sedation (chemical) or physical restraint, such as cuffs or ‘boxing gloves’. Management of agitated patients presents many issues for nurses in terms of staff morale, resource management and patient safety. Nurses might be concerned about the ethical issues underpinning the use of restraint. A recent court case highlighted that sedation cannot be classed as a deprivation of liberty to critical care patients as they physical illness is restricting their freedom, rather than any sanctions imposes by the hospital. Howver the use and role of physical restraint in management of agitation in critical care was not clarified.

Freeman et al. (2015) sought the opinions of nurses in relation to the use of physical restraint and  found some nurses expressed discomfort about the use of physical restraint and needed more education and support regarding physical restraint use. The authors of this blog are currently involved in further research in this area and would welcome your responses and opinions in this week’s Twitter chat., which will focus on:

  • How do you feel about caring for agitated patients?
  • Have you experienced problems with patient agitation where you work?
  • Do you receive help when managing agitated patients?
  • Do you use restraint?

https://medhealth.leeds.ac.uk/profile/1100/1715/angela_teece

https://www.research.manchester.ac.uk/portal/Samantha.Freeman.html

COLLINSWORTH, A. W., PRIEST, E. L., CAMPBELL, C. R., VASILEVSKIS, E. E. & MASICA, A. L. 2016. A Review of Multifaceted Care Approaches for the Prevention and Mitigation of Delirium in Intensive Care Units. J Intensive Care Med, 31, 127-41.

FREEMAN, S., HALLETT, C. & MCHUGH, G. 2015. Physical restraint: experiences, attitudes and opinions of adult intensive care unit nurses. Nurs Crit Care, 21, 78-87.

MION, L. C. 2008. Physical Restraint in Critical Care Settings: Will They Go Away? Geriatric Nursing, 29, 421-423.

Music therapy in improving the quality of life of palliative care patients: does it work?

8 May, 17 | by hnoble

Dr Joanne Reid, Reader in Cancer Nursing, School of Nursing and Midwifery, Queens University Belfast.

Research Collaboration in Northern Ireland between Queen’s University, ‘Every Day Harmony’ and Marie Curie Hospice Belfast, funded by the Public Health Agency, Northern Ireland.

Despite recent advances in medicine, patients with advanced illness continue to report high rates of suffering due to psychoexistential concerns such as loss of function, meaninglessness and anxieties in relation to death and dying. Palliative care recognises the ‘total pain’ experienced by end-of-life patients and supports the use of adjunct complementary therapies to address aspects of patient suffering still outside the remit of medical science and technology.

Music therapy is frequently used as a palliative therapy and entails the use of music to achieve individual goals in the context of a therapeutic relationship with a professional music therapist. Aligning with the goals of palliative care, the primary aim of music therapy is to improve people’s quality of life by relieving physical and psychological symptoms, facilitating communication and alleviating spiritual or existential concerns.

However, there are currently no guidelines in place for the use of music therapy in palliative care. This highlights the need for a stronger evidence base that demonstrates both the benefits and risks to help inform future music therapy provision. To date, primarily because of a lack of robust research, the evidence for music therapy’s effectiveness on patient reported outcomes is positive but weak. Music therapy is an allied health profession and can help a wide range of people affected by illness and disability. It uses musical interaction, and creativity through music, to address a patient’s clinical needs – whether they are psychological, physical, emotional, cognitive or social.

The core of music therapy is the relationship between the music therapist and the client. The client can either actively play instruments alone or with the music therapist, sing, or listen as they play. If the patient’s family is present, they may also be involved in the music therapy session. Patients can play to music already known to them, or play spontaneously and the therapist uses their musical skills to support them in this form of expression. Music therapy can also involve legacy work where the music therapist supports the patient to write a song for their family. In music therapy, our musical tastes and song choices can reveal the ‘person’ behind the terminal illness, helping patients reminisce about happier times, have fun in the moment, and leave a legacy for the future. As Shakespeare simply put it “When words fail, music speaks”

We are currently managing a study which is open for recruitment and running at Marie Curie Hospice Belfast with Music therapy provided by the Belfast based company Ever Day Harmony. A full study protocol is published elsewhere (DOI: 10.1186/s40814-016-0111-x ). The aim of the study is to determine the benefits of music therapy to people at the end of their lives. Fifty-two patients at the hospice are taking part. Half will receive six music therapy sessions over three weeks, as well as standard palliative care. The other half will receive standard palliative care (although they will also be offered up to two sessions of music therapy once the research period has finished). We will also collect data from HCPs and carers to understand their views on the impact of music therapy for patients. This is a feasibility study, with a view to undertaking a larger multi-site trial across the UK to evaluate the effectiveness of music therapy in improving the quality of life of palliative care patients.

Everyone has their own unique taste in music. It’s part of who we are. There’s been such a wide range of suggestions in the hospice so far: from classical music, such as Chopin, to traditional Irish music, to pop music. The music therapist delivering the intervention made a recent comment: I’ve learned so much from my clients. Everyone has so much to give, right up until the end, and it’s a privilege to be able to work with them at such an important time.”

 

Dementia Awareness Training with a Difference

3 Apr, 17 | by hnoble

Karen Galway and Catherine Monaghan, School of Nursing and Midwifery, Queen’s University Belfast, Medical Biology Centre, 97 Lisburn Road, Belfast Northern Ireland. BT9 7BL

 

This week’s EBN Twitter Chat on Wednesday 5th April between 8-9 pm (UK time) will focus on dementia, how we can break the taboo and improve education in this area.

The Twitter Chat will be hosted by Dr Karen Galway a Lecturer in Mental Health nursing At the School of Nursing and Midwifery, Queens University Belfast. Participating in the Twitter chat requires a Twitter account; if you do not already have one you can create an account at www.twitter.com. Once you have an account contributing is straightforward, You can follow the discussion by searching links to #ebnjc, or contribute by creating and sending a tweet (tweets are text messages limited to 140 characters) to @EBNursingBMJ and add #ebnjc (the EBN chat hash tag) at the end of your tweet, this allows everyone taking part to view your tweets.

The School of Nursing and Midwifery at Queen’s University Belfast has been championing improvements in dementia care through continuing professional development training over the past two decades.  The increasing prevalence of dementia, which has been referred to as the dementia tsunami, means that healthcare professionals need more training, support and resources to help alleviate symptoms and maximise quality of life. There is a clear need for specialised training as we continue to learn more about how to prevent, diagnose and treat the condition.

We teamed up with AFTAThought Training Consultants, to take our programme of training to a new level. AFTAThought was formed in 1988, and has been inspiring people to think differently ever since. “We’re passionate about what we do, delivering training through drama to bring issues, policies and legislation to life and we’ve trained just shy of a million people.”  Topics addressed in this inaugural partnership training included; public awareness, effective management, role of primary care, person centered care, communication challenges, identity, capacity and caregiving.

Approximately 300 students, researchers, statutory sector and voluntary sector health and social care professionals attended the event and we received some remarkable feedback indicating a strong and healthy appetite for this type of dementia training.  Many of those who provided feedback related the awareness training to their own personal experience with dementia, as a carer or as a professional.

Gary Mitchell, Research Coordinator at Four Seasons Healthcare commented on the training session; “You’re really filling a gap with this training. It is much needed.”

The awareness training was based on a local policy document (Dementia Learning Development Framework, 2016) and peer reviewed publications we have produced 1–4. The format was based a number of scenarios including; initial recognition of a problem by an individual, reactions from their family and the GP, disclosing a diagnosis and managing family dynamics, capacity to make decisions, transitions to nursing and residential care and hospital admissions. The session ended with a touching account of how it feels to be a family member caring for someone with dementia. There wasn’t a dry eye in the house, this training hit home and you could hear a pin drop.

We were thrilled to receive spontaneous feedback via email and from some students in subsequent classes. Some of these are quoted below;

“I just wanted to send an email to say what a fantastic experience and incredible insight the dementia lecture was. I lost my father to vascular dementia 18 months ago and was delighted to see that the experiences of family and the person living with dementia was so realistically and sensitively portrayed.”

“I was a student of yours way back in 2013. I attended the dementia awareness session yesterday & just wanted to get in touch to let you know I thoroughly enjoyed it. It was a very powerful and emotive experience.”

“Fantastic training! Really enjoyed the experience and a great insight to dementia. Puts things into perspective and creates a better way of thinking. Very overwhelming performance, it was brilliant.”

“That was the best lecture I’ve ever had”

On Wednesday 5th April during the twitter chat we will continue the conversation to consider these dementia questions that we have yet to answer;

  1. What are the best ways to break the taboo of dementia?
  2.  How can we best help people discuss and share their concerns, thoughts and feelings and maybe seek help earlier?
  3. What way should education be delivered, to allow all disciplines of health care professionals to access training that will increase the quality of dementia care?

Please join us to discuss this important medical, nursing and public health challenge.

References

1           Carter G, van der Steen J, Galway K, Brazil K. GPs’ perceptions of the barriers and solutions to good quality palliative care in dementia. Dement Int J Soc Res Pract 2015; In Press.

2           Brazil K, Carter G, Galway K, Watson M, van der Steen JT. General practitioners perceptions on advance care planning for patients living with dementia. BMC Palliat Care 2015; 14: 1–6.

3           Mitchell G, McCollum P, Monaghan C. The personal impact of disclosure of a dementia diagnosis: a thematic review of the literature. Br J Neurosci Nurs 2013; 9: 223–8.

4           Mitchell G, McCollum P, Monaghan C. Disclosing a diagnosis of dementia: A background to the phenomenon. Nurs Older People 2013; 25: 16–21.

Engaging Students with Twitter

26 Mar, 17 | by josmith

Kirsten Huby, Lecturer Children’s Nursing, University of Leeds (@KirstenHuby)

Emma Wilson, Children’s Nursing Student, University of Leeds (@Emzieness

The latest Horizon report (Adams Becker et al., 2017) recognises collaborative learning as one of the key trends that will be driving Higher Education for the next few years. It suggests that collaborative learning improves engagement, encourages learning that relates to practice and enables communities of practice to be developed. For healthcare students this type of learning can be used to develop the skills to think critically, problem solve and become open to recognising the diverse nature of the health and social care arena. Technology can help to promote collaborative learning but will only be successful if we can engage students and ensure they see the purpose of what is to be achieved.

 

It has been suggested social networking sites (SNS) encourage the type of collaborative learning advocated by (Adams Becker et al., 2017, Prestridge, 2014) ,we cannot assume that a particular type of SNS will necessarily work. In a study on the use of Twitter, students tended to use a tweet to ask a question of a lecturer rather than to collaborate between themselves. The author considers that students may need to be guided and supported to recognise the depth of knowledge and understanding that can be shared in this way (Prestridge, 2014). This implies that in order to be fully engaged students need to understand the purpose of the interaction and the tool that is being used.

To do this, informative learning opportunities and consultation with students needs to occur. The twitter community is diverse; some nurses opt to have separate ‘nursing’ accounts, others opt to combine professional and personal tweets as one online personality. Ultimately this comes down to personal preference. However, it must be considered that social media guidance has been set by the NMC (Nursing and Midwifery Council, 2015) and this and the requirements of the NMC Code must be adhered to at all times; on and offline and regardless of whether an account is identified as personal, professional or both. Student nurses therefore need to have an awareness of their responsibilities and potential accountabilities surrounding any social media use in relation to this.

A significant factor which potentially hinders student participation with SNS in a learning environment is whether they are comfortable with lecturers/mentors potentially having the ability to view personal posts/tweets. One such way around this is to have a specific agreement to not follow students back from University curated accounts. This means that students can view informative tweets / retweets on their timelines, but their own postings aren’t automatically or as easily visible. This leads to an element of ‘privacy’ and choice, allowing students to choose whether to engage with lecturers if they want to, but also benefit from some of the wider aspects of using SNS such as furthering knowledge / sharing views on current research or topical issues and collaborating and engaging with other students and professionals. As we take the next steps with the @UoLchildnursing account we hope to increase our engagement with students and with the help of motivated student twitter champions such as @Emzieness we hope this will be possible.

Adams Becker, S. et al. 2017. NMC Horizon Report: 2017 Higher Education Edition. 2017 ed. Austin, Texas: The New Media Consortium.

Nursing and Midwifery Council. 2015. Guidance on using social media responsibly. London.

Prestridge, S. 2014. A focus on students’ use of Twitter – their interactions with each other, content and interface. Active Learning in Higher Education. 15(2), pp.101-115.

Women with sickle cell disease carry additional risks for pregnancy

7 Mar, 17 | by josmith

Professor Allison Shorten, Director Center for Interprofessional Education and Simulation, University of Alabama, and Associate Editor Evidence-Based Nursing

 One of our most recent EBN commentaries reminds us of the health challenges faced by women with sickle cell disease globally. One of our expert commentators, Dr Eugene Oteng-Ntim from Guy’s and St Thomas’ Hospital, discusses a recent study by Bogfor et al (2016), highlighting the need for future research to address the high rates of maternal and infant morbidity and mortality associated with sickle cell disease in pregnancy. Globally, sickle cell disease is one of the most common genetic conditions, and when combined with pregnancy, risks are higher, regardless of whether women are living in low or high income countries. Read more about this recent systematic review and meta-analysis, and recommendations for health policy and clinical management.

Commentary: Oteng-Ntim, E. (2017) Pregnancy in women with sickle cell disease is associated with risk of maternal and perinatal mortality and severe morbidity, Evidence Based Nursing,

http://dx.doi.org/10.1136/eb-2016-102450

Reference:

Boafor TK, Olayemi E, Galadanci N, et al. Pregnancy outcomes in women with sickle-cell disease in low and high income countries: a systematic review and meta-analysis. BJOG 2016;123:6918.

Nursing attitudes to deliberate self-harm

6 Feb, 17 | by hnoble

Clare Carswell, Undergraduate mental health nursing student  & Dr Helen Noble, Lecturer, Queens University Belfast

Deliberate self-harm is a term that can be used to describe a variety of behaviours that involve an individual inflicting some form of physical harm to their own body. It is most typically associated with self-inflicted lacerations and self-poisoning. Self-harm is a growing issue, with an increase in the incidence within Britain and worldwide. A longitudinal examination of presentations to Irish hospitals for self-harm found an increase of 2-6% per year between 2006 and 2009 [See Perry et al 2012 http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0031663]. The most recent report by the Royal College of Psychiatrists (2010) also noted that self-harm is one of the five top causes of hospital admissions, although this report is due for review. http://www.rcpsych.ac.uk/pdf/position%20statement%204%20website.pdf

A number of studies suggest that only 10-20% of people who self-harm present to hospital or seek treatment and as the incidence of self-harm is typically measured by the number of people who present to hospital the scope of the issue could be vastly underestimated. While the increase in rate of self-harm globally, coupled with the existing high incidence, is valid justification for developing an understanding for practice in this area; another rationale for exploring the topic is the link between self-harm and suicide. Self-harm has been shown to be the most important factor when assessing risk of suicide meaning that appropriate early intervention is essential. Mental health trained practitioners are the professionals typically associated with providing comprehensive assessment and interventions, however the vast majority of individuals who self-harm will make first contact with emergency department personnel. It is crucial that the practice of emergency department nurses is compassionate, empathetic and effective in assessing and treating these patients, especially due to the associated risk of repeat episodes of self-harm and suicide following an initial presentation.

Attitudes can have a significant effect on behaviour meaning that the attitudes nurses hold can have an impact on their nursing practice. Patients who self-harm report high levels of stigma and negative attitudes, stating that they have been called ‘attention seeking’ or ‘manipulative’ as a result of the self-injurious behaviour. The text Blades, Blood and Bandages tells the stories of 25 people’s experiences of self-injury and investigates how those who self-injure are ‘affected by suffering, ritual and stigma’ http://www.palgrave.com/br/book/9780230252813

These negative attitudes and beliefs have originated from not only their friends and family, but also from medical professionals and emergency department personnel following presentation for their injuries. These attitudes can be interpreted through the professional’s behaviour and can have a profound effect on the patient. They can determine whether the patient decides to stay in the hospital for assessment, treatment or referral and whether they are instilled with a sense of hope and validation which in turn can help reduce the risk of further incidents of self-harm and even suicide. Attitudes can also have a more direct impact on nursing practice, for example nurses may feel unequipped or unprepared to perform a comprehensive assessment or to refer on to specialist mental health services. Referral to services can be problematic with this patient group. An understanding of the attitudes held by emergency department nurses may be able to inform areas for improvement in the education and practice of general nurses. One potential area for improvement could be a need for further education or training on the subject of self-harm, as an increased knowledge of self-harm has been shown to improve attitudes towards this patient group. Another area for improvement may be in the practice of emergency department nurses and improved access to mental health services, either through a mental health liaison nurse, a crisis intervention team or an unscheduled care team. More collaborative working between emergency departments and acute or community mental health services, and the opening of the lines of communication between services, may also be an appropriate change to practice. NICE Guidelines (2004) on self-harm recommend that emergency department services and mental health services should play a joint role in developing training on the treatment, assessment and management of self-harm. Emergency department nurses may feel that they do not have the resources, the capabilities, the appropriate skill set or be in the correct setting to adequately address the needs of the patient group meaning that involvement of mental health nurses could be crucial to improving the service provision for individuals who self-harm.

 

 

 

The power of reflection in nursing

30 Jan, 17 | by dibarrett

Lizzie Ette. Lecturer in Nursing, The University of Hull

This week’s EBN Twitter Chat is on Wednesday 1st February between 8-9 pm (UK time).

The chat will be led by Lizzie Ette (j.ette@hull.ac.uk ), Lecturer in Pre-registration Nursing, The University of Hull.

Participating in the Twitter chat requires a Twitter account; if you do not have one you can create an account at www.twitter.com. Once you have an account, contributing is straightforward. You can follow the discussion by searching links to #ebnjc, or contribute by creating and sending a tweet (tweets are text messages limited to 140 characters) to @EBNursingBMJ adding #ebnjc (the EBN Twitter chat hash tag) to your tweet, this allows everyone taking part to view your tweets

The power of reflection in nursing

As is so often the case, professional and personal lives are intricately related, and the recent experience of losing our family cat Reggie, following a road traffic accident at Christmas, really got me to reconsider the power of reflection on a personal level, and this got me thinking deeply about how important reflection is in my professional capacity, as a nurse.

  Reggie: 2000-2017

more…

Diaries for critical care patients

8 Jan, 17 | by josmith

Angela Teece (A.M.Teece@leeds.ac.uk)  Trainee Lecturer in Adult Nursing, University of LeedsAngela

Critical care is primarily concerned with curative interventions and the use of technology, and nursing and medical care to maintain life. Patients are frequently sedated for long periods of time that can causes memory loss and unusual perceptual experiences which can make it difficult for survivors to piece together the time they spent in critical care (Samuelson and Corrigan, 2009). The presence of delirium, which occurs in 35-80% of critical care patients (Collinsworth et al., 2016) further complicates recovery. The frequently nightmare dreams are more vivid than fragmented true recollections and can prevent patients developing an illness narrative and understanding the traumatic episode (Jones et al., 2001).

Critical care nurses have a duty to provide rehabilitative care (NICE, 2009). So how can nurses make a positive impact on their patients’ psychological recovery? Patient diaries are increasing in popularity in the UK after originating in Scandinavia. The subject of a recent Cochrane review (Ullman et al., 2015), the evidence base for diaries and guidance for those completing them remains scanty. However, the premise is simple and low cost. Nurses complete entries throughout the patient’s critical care admission, describing events and the environment in layman’s terms. The diary is given to the patient after discharge, often at a follow-up clinic where further support can be accessed. The aim is, simply, to fill in memory gaps and encourage discussion.

What do patients think of their diaries?

‘It was hard… to realise that it was actually about me, and that I could have died’ (Storli and Lind, 2009)diary

‘It is frustrating not to have all the information about one’s critical illness, and much energy is expended trying to piece information together’ (Engström et al., 2009)

‘It’s fantastic that you’ve gone to the trouble of doing this for me!’ (Storli and Lind, 2009)

Have you written in a patient diary?

Reading:

COLLINSWORTH, A. W., PRIEST, E. L., CAMPBELL, C. R., VASILEVSKIS, E. E. & MASICA, A. L. 2016. A Review of Multifaceted Care Approaches for the Prevention and Mitigation of Delirium in Intensive Care Units. J Intensive Care Med, 31, 127-41.

ENGSTRÖM, A., GRIP, K. & HAMRÉN, M. 2009. Experiences of intensive care unit diaries: ‘touching a tender wound’. Nursing in Critical Care, 14, 61-67.

JONES, C., GRIFFITHS, R. D., HUMPHRIS, G. & SKIRROW, P. M. 2001. Memory, delusions, and the development of acute posttraumatic stress disorder-related symptoms after intensive care. Critical Care Medicine, 29, 573-580 8p.

NICE 2009. Rehabilitation after critical illness. In: HEALTH, D. O. (ed.). London: Department of Health.

SAMUELSON, K. A. M. & CORRIGAN, I. 2009. A nurse-led intensive care after-care programme – development, experiences and preliminary evaluation. Nursing in Critical Care, 14, 254-263.

STORLI, S. L. & LIND, R. 2009. The meaning of follow-up in intensive care: patients’ perspective. Scandinavian Journal of Caring Sciences, 23, 45-56.

ULLMAN, A. J., AITKEN, L. M., RATTRAY, J., KENARDY, J., LE BROCQUE, R., MACGILLIVRAY, S. & HULL, A. M. 2015. Intensive care diaries to promote recovery for patients and families after critical illness: A Cochrane Systematic Review. International Journal of Nursing Studies, 52, 1243-1253.

Helping Older People with End Stage Kidney Disease make Decisions about Treatment

19 Dec, 16 | by hnoble

Dr Helen Noble, Lecturer & Clare Carswell, Undergraduate mental health nursing student, Queens University Belfast

me-1

There are at least 59,000 adult patients receiving renal replacement therapy to treat end stage kidney disease (ESKD) in the United Kingdom. In addition there are over 1.8 million people being treated globally – 77% treated with chronic dialysis and 23% living with a transplant. Kidney disease is categorised into five stages depending on the estimated glomerular filtration rate and evidence of kidney damage. The most severe of these stages is stage 5 Chronic Kidney Disease where the eGFR is < 15 ml/minute/1.73m (table 1).

bcmj_50_vol16_table1_stages

The number of older patients with ESKD is increasing annually as the population ages. The UK population aged over 65 is predicted to increase by 60%, from 10.3 to 16.9 million by 2035 [https://esa.un.org/unpd/wpp/], and increased numbers of older patients will commence dialysis worldwide. Older patients who require dialysis report a higher burden of “geriatric syndromes”. These include frailty, falls, and cognitive impairment. There is also evidence that dialysis initiation may be associated with accelerated rates of functional and/or cognitive decline [https://www.ncbi.nlm.nih.gov/pubmed/15507063]

Renal replacement therapy includes haemodialysis, peritoneal dialysis or transplantation but choices regarding treatment are perplexing. One particularly difficult decision concerns older people with ESKD, unsuitable for transplantation, who have to decide between dialysis and conservative management. Dialysis involves coming to hospital three times a week for four hours each visit and requires attachment to a dialysis machine which filters the blood and replaces the role of the damaged kidneys. Conservative management offers a supportive and palliative approach to care, without dialysis. Patients are supported and followed up by a multidisciplinary team often in their own homes. Some people regret their decision to start dialysis and some may go on to withdraw from treatment. Others report that they didn’t fully understand the decision they were making. There is a need to ensure that patients making decisions between dialysis and conservative management are supported through this process. Decision-aids may help people who are facing these difficult health treatment decisions.  Decision-support interventions encourage people to be more actively involved in decision making, improve risk perceptions and congruence between the choice made and their personal values. They may also help improve communication between patients and staff.

There are limited decision-support interventions available to assist with complex decision-making in people who are choosing between dialysis and conservative management. The OPTIONS decision-aid has been developed in Australia and is being tested in a multisite randomized controlled trial [http://www.readcube.com/articles/10.1111/jan.12921]. A similar tool is being developed in Ottawa, Canada. In the UK, The excellent ‘Dialysis Decision Aid’ has been developed to help people make decisions about renal replacement therapy but it has less of a focus on conservative management and is aimed at all age groups [https://www.kidneyresearchuk.org/DialysisDecisionAid].

In the UK there is a need to develop a UK specific decision-aid for people deciding between dialysis and conservative management in order help patients with kidney disease make the best possible decision. In order to test such an aid a randomised trial similar to the one in Australia is recommended.

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