Advanced practice providers have an important role in kidney supportive care
Click Here to Manage Email Alerts
For more than 2 decades, nephrologists and patients have recognized the key role nephrology advanced practice providers have played in the care of patients with chronic kidney disease.
Patients have indicated that advanced practice providers (APPs; nurse practitioners, physician assistants and clinical nurse specialists) provide sympathetic, personal care and the contribution that they make to the quality of patient care is exceptional.
In their training, APPs are prepared to provide high-quality care and instructed to cope with the complexities of managing patients with CKD. The International Council of Nursing describes advanced practice nurses, including nurse practitioners and clinical nurse specialists, as nurses who have acquired — through additional graduate education (at least a master’s degree) — the expert knowledge base, complex decision-making skills and clinical competencies for advanced nursing practice.
The National Kidney Foundation Council for Advanced Practice Providers (CAPP) conducts a biannual survey addressing the roles of nephrology APPs (see article on the results of the most recent survey starting on page 12), and reveals most APPs practice within CKD clinics, dialysis units, and pre- and post-transplant. There is not yet mention of supportive care practices; however, many APPs deliver supportive care to patients on dialysis, those who have opted to forego dialysis and those within the kidney palliative care space.
Palliative care
With its attention to the psychosocial and spiritual aspects of care in addition to the physical, it is expected that nephrology nurse practitioners would also play a major role in the palliative care for patients with kidney disease. In particular, nephrology nurse practitioners have been observed to be skilled in using the “surprise” question — “Would I be surprised if this patient died in the next year?” — to identify the sickest patients in dialysis centers and who are appropriate to receive priority for palliative care.
As part of the kidney care team, APPs educate patients about kidney failure treatment options, including palliative dialysis and active medical management without dialysis. Also, nurse practitioners have been noted to play a significant role in the palliative care skills of goals-of-care conversations, advance care planning and Portable Orders for Life-Sustaining Treatment (POLST, or similar term depending on the state) completion.
APPs provide a number of essential contributions in kidney supportive care (see Table). Each element focuses on a different aspect of their role, emphasizing the holistic and multifaceted nature of their responsibilities.
Palliative nephrology program
After discovering that many patients did not want to proceed with dialysis or subsequently, a home palliative care referral, the author developed and implemented an active medical care without dialysis program to provide continued supportive care at a safety net academic medical center in Kansas City, Missouri. Buy-in from leadership and physician chairs was obtained and conservative care visits became part of the CKD clinic for patients in stage 4-5. Resources from the Coalition for Supportive Care of Kidney Patients and Conservative Kidney Management (ckmcare.com) supported program development. Interprofessional team members, such as social workers and chaplains, supported patients with psychosocial or spiritual needs and referral to hospice care when indicated. Additional collaboration occurred with the palliative care medical director and department of nephrology as needed to manage symptoms and CKD sequelae, focusing on patient-centered care.
With the conservative kidney care program underway, patients choosing to forgo dialysis or withdraw from dialysis have an established support system in place, goals of care documented and wishes supported and honored.
As predicted more than 20 years ago, APPs have lived up to their potential and certainly proven their worth in both nephrology and palliative care, supporting person-centered care and improving quality of life and well-being for patients with CKD and their families.
- References:
- American Association of Nurse Practitioners. www.aanp.org.
- Learn more about the PA profession. American Association of Physician Assistants. https://www.aapa.org/about/what-is-a-pa/.
- American Nephrology Nurses Association. Position statement: Nephrology nurse’s role in palliative and end-of-life care. http://anna.inurse.com/download/reference/health/position/palliativeCare.pdf.
- Bolton WK. J Am Soc Nephrol. 1998;doi:10.1016/s0272-6386(98)70047-2.
- Constantine LA, et al. J Palliat Med. 2020; doi:10.1089/jpm.2020.0515.
- Corbet CM (2022). Active medical management without dialysis. In S.M. Bodin (Ed.), Contemporary Nephrology Nursing (4th ed, pp. 187-217). American Nephrology Nurses Association.
- Corbett CM, et al. Nephrol Nurs J. 2021;doi:10.37526/1526-744X.2021.48.1.69.
- Dahlin CM, Lynch MT. Evolution of the advanced practice nurse in palliative care. In: Dahlin CM, Lynch MT (Eds.), Core Curriculum for the Advanced Practice Hospice and Palliative Registered Nurse (2nd ed.). Pittsburgh, Pa.: Hospice and Palliative Nurses Association; 2013.
- Dahlin CM. Providing quality palliative care. In: Dahlin CM, Lynch MT (Eds.), Core Curriculum for the Advanced Practice Hospice and Palliative Registered Nurse (2nd ed.). Pittsburgh, Pa.: Hospice and Palliative Nurses Association; 2013.
- Hemmat V, et al. Crit Care Nurs. 2022;doi:10.1016/j.cnc.2022.07.003.
- International Council of Nurses. Guidelines on advanced practice nursing 2020. https://npac-aiipc.org/wp-content/uploads/2020/07/ICN_APN-Report-EN.pdf.
- Moss AH, et al. Clin J Am Soc Nephrol. 2008;doi:10.2215/CJN.00940208.
- Nozu H, et al. Plos One. 2024;doi:10.1371/journal.pone.0301676.
- Renal Physicians Association. (2010). Shared decision-making in the appropriate initiation of and withdrawal from dialysis. https://cdn.ymaws.com/www.renalmd.org/resource/resmgr/Store/Shared_Decision_Making_Recom.pdf. Rockville, Md.
- For more information:
- Christine Corbett, DNP, APRN, FNP-BC, CNN-NP, FNKF, is the executive director of the Coalition for Supportive Care of Kidney Patients (www.kidneysupportivecare.org/). Corbett is also an assistant research professor at George Washington University School of Medicine and can be can be reached at christine.corbett@email.gwu.edu.
Collapse
Read more about
Click Here to Manage Email Alerts