End of life issues and advance care planning in the elderly patient

Mr. J. achieved the desired outcome that was the best for him and his family. It remains to be seen how his trial of dialysis will fare. To date he is doing well and has not been readmitted to the hospital. The shift in his opinion regarding what would be the best decision for him has been significant, an evolutionary process, and followed a predictable course. When presented early, in a non-emotional situation, perhaps greater numbers of patients will have advance directives signed and in place when the decision to start or withdraw from dialysis are imminent. Recognizing that advance care planning is one facet of end-of-life planning will remind the nurse to look at all of the components in designing a patient plan of care. Further, knowing that this is an evolutionary process and should be revisited frequently will enable the nurse to incorporate the understanding that palliative care/hospice should be offered with dialysis, instead of taking an either/or approach. The unique issues facing the older adult also need to be evaluated and discussed with the patient/family. An acknowledgement of co-morbid conditions, mental status, and ambulatory status will help guide the nurse in estimating the best possible outcome and success of initiation of treatment. Nephrology nurses need a constant reminder that patients can change their minds at any point. As the dialysis population and number of patients with CKD continue to grow, the nephrology nurse practitioner and nephrology community are obligated to revisit and evaluate the success of their personal implementation of the guidelines that have been so rigorously formulated.