Pathway Project results were presented for the first time at ASN Kidney Week, revealing three new best practices for end-of-life care, specific to the kidney community.

“Although there’s an increasing body of evidence outside of nephrology that says care practices can improve quality of life, confidence in end-of-life decision-making and bereavement, there is a lag in translating these findings into practice,” Manjula Kurella Tamura, MD, MPH, director of the Geriatric Research and Education Clinical Center at the Veterans Affairs Palo Alto Health Care System and professor of medicine at Stanford University, said.

The Pathway Project identified and presented 14 evidence-based best practices that could be incorporated into kidney care to dialysis organizations, then refined the final package to prioritize three best practices. These practices focused on seriously ill patients.

The first best practice of the Pathway Project encourages nephrologists to screen patients by asking themselves the “surprise” question: “Would I be surprised if this patient died in the next 6 or 12 months?” Answering no would mean that the patient is seriously ill. The second best practice is to prioritize goals of care conversations with seriously ill patients. The third best practice is offering palliative care pathways that allow patients to transition to less frequent dialysis, hospice or dialysis discontinuation based on their goals of care.

Ten hemodialysis centers voluntarily adopted and implemented these practices after two learning sessions. The serious illness screening was implemented and sustained, even after the beginning of the COVID-19 pandemic, in early 2020 throughout all the centers.

“In terms of the next best practice, conducting goals of care conversations, sites monitored the implementation of this practice by tracking the percent of seriously ill patients who had a goals of care conversation within 30 days of hospital discharge,” Kurella Tamura said. “What they found is that goals of care discussions were implemented, but unevenly, over the course of the implementation.”

She said a few reasons that implementation was challenging were scheduling issues, lack of confident caregivers to have these conversations and some patients felt they could continue putting off the conversation.

The third best practice, the palliative care pathway, was implemented the least, and no centers developed protocols to transition patients to hospice or dialysis withdrawal. A given reason for this was the CMS payment structure and that removing a patient from dialysis could negatively affect paid caregivers.

When interviewed 18 months after implementing the Project Pathway practices, many caregivers involved expressed positive thoughts about the practices.

“We found that all of the sites encountered challenges, but also found this experience incredibly rewarding both for their own individual practice, as well as the practice for their center as a whole,” Kurella Tamura said. “While there were many successes, there were still some hurdles that couldn’t be overcome in the project, particularly the policy and resource barriers that are inherent in our current health care system. So, in some ways, it’s not surprising that a learning collaborative just by itself was not able to overcome these barriers. Maybe one of our takeaways is that the learning collaborative needs to be coupled with changes at the policy and health care structure level to be able to see meaningful changes in health care utilization and patient experience near the end of life.”