ODN supportive care work stream - What’s the issue we are addressing ? What have we already done ? What would we like to do What’s your role in all of this ?
Patient 3 88 yr old at time of treatment decision • Pulmonary TB 1950s - 30- May-2014 • Asthma - 30-May-2014 • Hypertension - 30-May- 2014 • Hypercholesterolaemia - 30- May-2014 • Pre-eclampsia with first child - 19-Jun-2014 • GFR = 7
Patient 3 88 yr old at time of Patient 3 alive at 93 treatment decision • • GFR 6-7 Pulmonary TB 1950s - 30-May- 2014 • Pottering successfully • Asthma - 30-May-2014 • No major intervening life • Hypertension - 30-May-2014 events • Hypercholesterolaemia - 30- May-2014 • Pre-eclampsia with first child - 19-Jun-2014 • GFR = 7 (no available trajectory as presented late)
Patient 4 - aged 85 at time of treatment decision • Probable diabetic nephropathy - 18-Aug-2006 • Hypertension 1980's - 18-Aug- 2006 • Obesity - 18-Aug-2006 • DM care GP, Eyes KCH - 17-Oct- 2007 • AF - 21-Aug-2017 • Stroke - R quadrantinopia - 21- Aug-2017 • Left femoral popliteal bypass graft, plastied 2/2011 - on Aspirin and Warfarin until 2017 - 14-Sep- 2017
Patient 4 - aged 85 at time of Events treatment decision • • Probable diabetic nephropathy - Sept 2017 seen in LCC and decided to go for HD • Nov 2017 – developed symptoms 18-Aug-2006 • 7 th Dec 2017 AVF formed – weak thrill and bruit • • Jan 2018 seen in LCC. AVF not matured – decision for HD Hypertension 1980's - 18-Aug- revisited & referred to supp care clinic 2006 • April 2018 – decision made for SC • Continued to be seen at home with symptom management. • Obesity - 18-Aug-2006 • Frequent phone calls in between visits as necessary • Dec 2018 – seen at home. Deteriorating and generally less • DM care GP, Eyes KCH - 17-Oct- well and increasingly frail – referred to St C’s. • Jan 2019 – joint home visit with St C’s 2007 • March 2019 – admitted to KCH under gastro team with D&V. • Treated with Abs. AF - 21-Aug-2017 • Decision re RRT revisited and very clear did not want RRT • • Stroke - R quadrantinopia - 21- Further deterioration and end of life care and PPC discussed • PPC hospice as not ideal home environment (not suitable/no Aug-2017 room for equipment) and husband not in best of health and felt wouldn’t cope • Left femoral popliteal bypass • Transferred to St C’s hospice on 2 nd April where died peacefully on 16 th April with husband and niece present graft, plastied 2/2011 - on Aspirin • May 2019 - Follow up with husband. He felt sup care was the and Warfarin until 2017 - 14-Sep- right decision and was happy that she had a peaceful death in the place of her choice 2017
Patient 2 - aged 87 at time of treatment decision • OA - 12-Jun-2008 • Rt THR and Rt TKR (complicated by #patella) - 28-Oct-2009 • Speaks Turkish only - 28-Oct-2009 • SMD and cataracts - 28-Oct-2009 • Hysterectomy and cholecystectomy - 28-Oct- 2009 • Hypertension, dyslipidaemia - 21-Apr-2011 • Osteoporosis - 04-Jul-2013 • on CPAP for OSA - 04-Sep-2014 • Wheelchair bound - 02-Aug-2017 • 2017 Lt ICA stenosis - 12-Feb-2018 • CKD stage V - HTN +/- RAS - 09-May-201 • Multiple clinic attender
Patient 2 - aged 87 at time of treatment decision • 8 opds in AKCC over 14 months • • OA - 12-Jun-2008 For second opd she had clear discussions about dialysis not thought to help extend life • Rt THR and Rt TKR (complicated by #patella) - (limited discussions in nephrology) 28-Oct-2009 • Patient had significant cognitive challenges • Speaks Turkish only - 28-Oct-2009 • Family very keen for her to have HD or PD • SMD and cataracts - 28-Oct-2009 • Met our SC sister • Hysterectomy and cholecystectomy - 28-Oct- • 2009 Missed multiple further opds because too ill to travel (severe uraemic symptoms) • Hypertension, dyslipidaemia - 21-Apr-2011 • Declined attempts by both hospital and GP • Osteoporosis - 04-Jul-2013 staff to involve community palliative care and • on CPAP for OSA - 04-Sep-2014 set up an end of life plan • Wheelchair bound - 02-Aug-2017 • Presented to local A and E in extremis • 2017 Lt ICA stenosis - 12-Feb-2018 • Family declined a plan for her to be kept • CKD stage V - HTN +/- RAS - 09-May-201 comfortable and requested intubation • Multiple clinic attender • Patient died in A and E intubated and distressed
Patient 5 - aged 66 at time of treatment decision • Type 2 diabetes 2005 with poor control 27-Jun-2013 • Obesity - 27-Jun-2013 • Obsessive compulsive disorder - Lithium 1985 - Stepping Stones Community Mental Health Team - 27-Jun-2013 • Hypertension 2013 - 27-Jun-2013 • Psych assessment (Stepping Stones) - reducing doses of Lithium - 06-Sep-2013 • Ex smoker stopped 1985 - 15-Apr-2014 • Likely IHD - Angio planned post AVF (J. Byrne) - 30-Oct-2015 • Aug 2015 Central retinal artery occlusion (Left eye). Moorfields - 14-Jan-2016 • Oct 2015 Rubeotic glaucoma post L central retinal artery occlusion - PRPV - 14-Jan-2016 • L vitreous haemorrhage - 14-Jan-2016 • Left MCA infarct with residual weakness and dysphasia - 07- Oct-2016 • Started HD Sep 2016 - 07-Oct-2016 • April 19- on level 6 soft and bite sized diet (IDDSI 6) and level 1 slightly thick fluids (1 scoop nutilis clear to 200ml) - 11-Mar- 2019
Patient 4 - aged 66 at time of Patient 5 - aged 66 at time of treatment decision treatment decision • March 2019 – Consultant & sup care CNS saw on • Type 2 diabetes 2005 with poor control 27-Jun- HD for increasing symptoms including extreme 2013 pain from DM foot. Changed analgesia. • Obesity - 27-Jun-2013 • April 2019 - admitted following an unresponsive • Obsessive compulsive disorder - Lithium 1985 - episode on HD – deteriorating on HD Stepping Stones Community Mental Health Team - 27-Jun-2013 • Met with husband spoke about whether now • Hypertension 2013 - 27-Jun-2013 was the right time to stop dialysis. • Psych assessment (Stepping Stones) - reducing • He spoke openly about feeling that he lost her in doses of Lithium - 06-Sep-2013 May 2016 after she had the stroke and feels that • Ex smoker stopped 1985 - 15-Apr-2014 her condition has further deteriorated • Likely IHD - Angio planned post AVF (J. Byrne) - significantly in April this year 30-Oct-2015 • • Aug 2015 Central retinal artery occlusion (Left Refuses to go for dialysis /oral intake minimal. eye). Moorfields - 14-Jan-2016 • Has not got the mental capacity to make a • Oct 2015 Rubeotic glaucoma post L central decision about her health care. retinal artery occlusion - PRPV - 14-Jan-2016 • • Team agreement with NOK that dialysis no L vitreous haemorrhage - 14-Jan-2016 • longer having a positive effect and that we Left MCA infarct with residual weakness and dysphasia - 07-Oct-2016 support a decision to stop dialysis • Started HD Sep 2016 - 07-Oct-2016 • Urgent referral made to St C's for care home • April 19- on level 6 soft and bite sized diet (IDDSI support. 6) and level 1 slightly thick fluids (1 scoop nutilis • PPC – care home with St C’s support clear to 200ml) - 11-Mar-2019 • Died peacefully 16/05/19 at care home
What is supportive care ? • Right care – Dialysis where helpful – Supportive care/CGA/ end of life care • Right patient – What do they want – From what might they benefit • Right time • Early signposting • Changing goals through renal journey • • When applied to our more elderly and more frail patients
Key facts • Late stage kidney disease considerably shortens life expectancy compared to aged matched controls (worse than many cancers) • Older dialysis patients do much less well than younger ones • For those starting dialysis from a nursing home (or equivalent) only 13% are alive and at the same functional level one year later (others have died or declined) • The benefits of dialysis in terms of life expectancy and QOL are less clear for - patients over 65 with significant co-morbidity and patients over 80 • Dialysis patients can still have significant symptom burden • Some older patients do really well on dialysis , gain years of life and improve their symptom burden - UNCERTAINTY
Total South London advanced kidney care patients by age • 451 patients between the Total South London pre-dialysis age of 65 and 80 patients by age • 364 patients who are over the age of 80 • On average those with > 80 yrs 364; 21% advanced CKD are < 65 yrs 931; 53% 65-79 yrs physiologically 10 years 451; 26% older than their chronological age
Older Dialysis patients in South London 953 are 65 – 79yrs ; 467 are > 80yrs Total South London HD patients by age Total South London PD patients by age 35 ; 12% 432 ; 17% 1,304 ; 50% 92 ; 33% 153 ; 55% 861 ; 33% PD patients under 65 PD patients 65><80 PD patients over 80 HD patients under 65 HD patients 65><80 HD patients over 80
Recommend
More recommend
