KEY POINTS:Most of the nephrology fellows express concern about health care disparities. A significant proportion of nephrology fellows do not feel well-trained to reduce care disparities. We highlight an opportunity to optimize nephrology education about disparities and equip future nephrologists to reduce inequities in kidney care. BACKGROUND:Equity in kidney care is clinically and ethically important. We conducted a national survey of nephrology fellows to assess their attitudes toward, and perceptions of, health equity in fellow training and kidney care. METHODS:We administered a 13-question survey in 2022 to all nephrology trainees through the American Society of Nephrology in-service training exam. We asked fellows about their perceptions of training and confidence in caring for underserved patients, their level of concern about health disparities, and the sense of responsibility they felt to address these disparities. Baseline characteristics were summarized, and survey responses were analyzed using factor analysis and multivariate modeling. RESULTS:The response rate was 84% (689 of 816). The survey reliability factor was 0.77, i.e ., very good to excellent. Respondents were a mean (SD) of 34 (4) years, 57% were men, and 11% Hispanic. Most (72%) reported working with underserved populations "often/always". Over 80% of fellows "agreed/strongly agreed" that they were concerned about health care disparities. Only 61% "agreed/strongly agreed" they were well-trained to reduce disparities. Individuals of self-reported Hispanic and Black race, as well as US Medical School-based graduates, were more likely to report working with underserved patients. Black trainees demonstrated greater concern for addressing health disparities and higher confidence in their ability to work effectively with underserved populations ( P = 0.04). Nonetheless, they reported feeling less well-trained in cross-cultural communication compared with White trainees ( P = 0.01). In factor-weighted, multivariate analysis, concern in women versus men was not significantly different, yet confidence to address disparities, cross-cultural communication, and self-efficacy caring for underserved patients was lower in women (all P ≤ 0.05 compared with men). CONCLUSIONS:Although a physician's skills in cross cultural communication, and abilities to care for underserved individuals and to address health disparities are critically important, a significant proportion of nephrology fellows reported not feeling confident and/or lacking experience in these areas. There is an urgent need to optimize nephrology training in these areas, to empower the next generation of nephrologists to provide disease-specific communication and care for the diverse populations they serve.

Background: Identifying goals of care is important for patients suffering severe ischemic stroke (SIS) and their caregivers to ensure patient- and family-centered treatment decisions. This study sought to determine the prevalence and patient predictors associated with having a documented goals-of-care conversation (dGOCC) after SIS. Methods: We reviewed the medical charts of all patients with National Institutes of Health Stroke Scale (NIHSS) [≥]10 admitted to four hospitals in the Midwestern US. In addition to sociodemographic and clinical characteristics, we searched for dGOCC during the acute stroke hospitalization, defined as any documented conversation or meeting that addressed one or more of the following domains: prognostic information, treatment plan, patient preferences and values, quality of life, or establishing goals. We determined prevalence, frequency, timing, and content of dGOCCs. Additionally, we obtained information on treatment utilization and outcomes. Results: Among 1297 patients, 26.5% (n=344) had at least one dGOCC. Treatment plan was the most discussed domain (n=264, 20% of all patients) and was the most common first dGOCC (n=207, 60% of first conversations). Median day for first dGOCC was on hospital day zero. Patient preferences, values, and goals were documented in 112 (8.6%) of all patients' charts and quality of life conversations were documented in only 61 (4.7%) charts. In multivariate analysis, having a NIHSS [≥]21 (OR 1.46, p-value .01) was associated with having a dGOCC. Conclusion: After severe stroke, most patients do not have a dGOCC, despite the important decisions that often arise about treatment and rehabilitation. Documentation of patient preferences, values and goals are even rarer. This suggests missed opportunities for high quality decision making informed by patient goals to improve person centered care.

BACKGROUND:Chronic Kidney Disease (CKD) impacts ~40% of US adults aged ≥ 60 years. Palliative care, which can improve symptoms of serious illness, is underutilized in CKD despite it's association with a high symptom burden. We conducted a scoping review of palliative care interventions in CKD, with particular attention to older adults. METHODS:We searched PubMed, CINAHL, EMBASE, Cochrane Central, PsycInfo, ClinicalTrials.gov, and Web of Science for: (1) kidney disease; (2) palliative care; and (3) study design. Palliative care interventions were defined as medical strategies that address ≥ 1 domain of the Clinical Practice Guideline for Quality Palliative Care. We characterized studies, quantified palliative care domains assessed, summarized symptom and quality of life outcomes, and identified studies limited to older adults. RESULTS:Of 2046 studies screened, 25 (1%) met inclusion criteria. Ten studies (40%) were randomized controlled designs. The most common quality domains addressed were physical aspects of care (21, 84%) and structure and processes of care (16, 64%). Twenty-four (96%) studies measured symptoms, 12 (48%) measured quality of life, and 11 (44%) measured both. Twenty-one different instruments were used to measure symptoms or quality of life. Six (24%) studies were limited to older adults. CONCLUSIONS:In our sample of studies evaluating CKD palliative care interventions, limited quality domains were addressed, a variety of measurement tools were used, and less than a quarter of studies were conducted only in older adults. Future research should address the holistic nature of palliative care, apply standardized instruments, and increase inclusion of older adults.

Importance:Older adults represent the fastest-growing population initiating dialysis in the US. For older adults with advanced chronic kidney disease (CKD), initiating dialysis is often the default option presented, as they are often ineligible for kidney transplant. This approach may not align with many older patients' goals, who often prioritize quality of life over life extension. Further, many older patients report not being informed about all available kidney therapy options. This narrative review provides a guide for primary care clinicians to collaborate closely with older adults, their families, and nephrologists to promote shared kidney therapy decision-making in advanced CKD. Observations:Several options exist for older adults with advanced CKD. These include kidney transplant, which aims to prolong life while preserving a good quality of life; dialysis, which focuses on prolonging life; and conservative kidney management, which forgoes dialysis and transplant, prioritizing quality of life over life prolongation. Shared decision-making is a collaborative process in which clinicians and patients jointly develop a care plan based on the best available evidence, the patient's goals and prognosis, and a careful weighing of the pros and cons of each kidney therapy option. This process supports patients to achieve informed and goal-concordant decisions regarding CKD management after careful deliberation. For patients with decisional uncertainty or a desire to maintain the status quo, a time-limited trial of dialysis or a deciding not to decide approach, respectively, can be implemented. Conclusions and Relevance:Shared decision-making is essential to help older adults with advanced CKD understand therapy options and make goal-concordant decisions. Primary care clinicians' collaboration with nephrologists to promote shared decision-making and deliver patient-centered, coordinated care is critically important.

Rationale & Objective: Older adults in the United States often receive kidney therapies that do not align with their goals. Palliative care (PC) specialists are experts in assisting patients with the goals of care discussions and decision support, yet views and experiences of older patients who have received PC while contemplating kidney therapy decisions and their nephrologists remain unexplored. We evaluated the acceptability of CKDEDU, a PC-based kidney therapy decision support intervention for adults >= 75 years of age. Study Design: Qualitative study. Setting & Participants: Two trained research coordinators interviewed patients and nephrologists participating in the CKD-EDU study. Analytical Approach: Three coders analyzed the qualitative data using a thematic analysis approach to identify salient themes pertaining to intervention acceptability. Results: Patients (n = 19; mean age: 80 years) viewed the PC intervention favorably, noting PC physicians' excellent communication skills, whole-person care, and decision-making support, including comprehension of prognostic information. Nephrologists (n = 24; mean age) welcomed PC assistance in decision making, support for conservative kidney management, and symptom management; a minority voiced concerns about third-party involvement in their practice. Limitations: Single-center study. Conclusions: Overall, patients and nephrologists generally found the PC intervention to be acceptable. Future testing of the current PC-based decision support intervention in a larger randomized controlled trial for older people navigating kidney therapy decisions is needed.

BACKGROUND AND OBJECTIVE:The issue of racial and ethnic disparities in healthcare has been a significant concern for many years. It encompasses various aspects, including disease prevention, diagnosis, management, and end-of-life (EOL) care. Research has found that timely intervention with palliative care can result in better EOL care and reduced healthcare costs. This review aims to detail the role of healthcare disparities impacting palliative care, hospice enrollment, and EOL care in patients with serious illnesses who are facing EOL. It addresses the factors that play a role in creating these disparities and describes specific interventions that may reduce disparities in the provision of EOL care. METHODS:Authors searched, PubMed Central, Medline, and PubMed databases using Racial Disparity and End-of-Life/Palliative Care combinations. A total of 57 studies were identified. All articles were reviewed, and the available evidence was synthesized and to identify key domains in EOL care impacted by racial disparities and the factors contributing to them. KEY CONTENT AND FINDINGS:Several patient, provider, and institutional level factors may be responsible for disparities seen in EOL care, including health literacy, access to care, mistrust of the healthcare system, social determinants of health (SDH), medical racism, cultural and religious customs, and communication at EOL. Disparities in EOL care experienced by minority patients is an extension of the systemic and institutionalized racism rampant in the healthcare system. Providers must work on multiple fronts to address this inequity and injustice, the first of which is recognition and conversation regarding disparities in EOL care. CONCLUSIONS:Disparities in communication, palliative and hospice care utilization, and symptom management must be eradicated. Palliative care and hospice should be made accessible for all patients and families experiencing severe illness regardless of their racial or ethnic background.

BackgroundDialysis is often initiated in the United States without exploring patients' preferred decision-making style, and conservative kidney management (CKM) is infrequently presented. To improve kidney therapy (KT) decision-making, research on nephrologists' comfort with various decision-making styles, attitudes towards CKM, and reports of patients' lived experiences with KT decision-making is needed.MethodsWe surveyed 28 nephrologists and 58 of their patients aged ≥75 years. The nephrologist survey was designed to gauge their comfort levels with decision-making styles and attitudes towards CKM. The patient survey assessed experiences in making KT decisions.ResultsThe average age of nephrologists was 43 years, and that of patients was 82 years. Nephrologists rated themselves as comfortable with various decision styles: paternalistic (60.7%), shared decision-making (92.8%), and patient-driven decision-making (67.8%). Nearly 57% of nephrologists felt challenged or were neutral in determining CKM's suitability, and 39% reported difficulties in discussing CKM with patients or were neutral. Only 38 % of patients recalled discussing CKM with their nephrologists, and a minority reported discussing CKM-related topics such as life expectancy (24.7%), quality of life (QOL) (45.1%), and end-of-life care (17.5%).ConclusionsMost nephrologists displayed comfort with various decision-making styles; however, many described difficulties in guiding patients toward CKM. In contrast, patients reported gaps in vital aspects of KT decision-making and CKM choices, such as discussions of life expectancy, QOL, and end-of-life care. Raising awareness of blind spots in decision-making skills and educating nephrologists in KT decision-making to include CKM and other person-centered aspects of care are needed.

ObjectivesIn this review, we examine the impact of sex and gender on advanced stroke interventions and end-of-life outcomes after stroke and discuss the current theories, available evidence, and gaps in the literature.MethodsA scoping review of the literature was conducted to determine gender differences on advanced stroke interventions and end-of-life outcomes after stroke. The study team utilized PubMed to conduct a review of the literature and included research studies related to sex, gender, advanced stroke interventions, and end-of-life outcomes after stroke. The PRISMA process for conducting a scoping review was followed.ResultsThis review found that although evidence regarding gender differences in advanced stroke interventions and end-of-life care after stroke is disparate, some gender differences do indeed exist. Women are less likely to receive thrombectomy or alteplase, women are more likely to receive palliative care intervention, hospice, and women experience stroke mortality at higher rates.ConclusionsGender differences in end-of-life care after stroke are apparent with women experiencing lower rates of life sustaining interventions, and higher rates of mortality, palliative and hospice care. More research is needed to identify variables associated with or responsible for gender differences during advance interventions and end-of-life care after stroke.

Outcomes1. Identify key themes about religion, faith, and spirituality documented during goals of care conversations with acute stroke patients.2. Apply new knowledge about gaps in documenting goals of care conversations about religion, faith, and spirituality.Key MessageThis study analyzed the prevalence and themes of documented goals of care conversations about religion, faith, and spirituality. The study found infrequent documentation. Additionally, we found when patients expressed religious belief or spiritual value, there was little evidence that the team explored how these statements might affect care decisions.ImportanceGoals of care conversations (GOCC) are vital to patient-centered care, especially during an acute, unexpected medical event such as a severe ischemic stroke. There is a paucity in the literature regarding the frequency and depth in which religion, faith, or spiritual beliefs are addressed during GOCCs.Objective(s)To determine the content of religion, faith, or spiritual beliefs addressed during GOCCs documented by the interdisciplinary team in the patient's medical record.Scientific Methods UtilizedA qualitative, thematic analysis of documented GOCC (dGOCC) was undertaken from a larger multicenter cohort study of patients suffering from an acute severe ischemic stroke. The parent study abstracted content of dGOCC from the medical records of 1297 patients and categorized the content into five domains of a GOCC, of which one domain was religion, faith, and spiritual beliefs. This study performed thematic analysis on the subset of patients with a dGOCC regarding religion, faith, and spiritual beliefs.ResultsAmong the 1297 patients with a dGOCC, 47 (3.6%) patients had at least one dGOCC about religion, faith, or spiritual beliefs. Thematic analysis identified five themes within dGOCC: 1) the patient's or family's religion was identified; 2) religious or spiritual support was provided to the patient and or their family; 3) the role religion, faith, or spirituality plays in the patient's and/or their family's daily lives; 4) the role of religion, faith, or spirituality in coping with illness and/or the hospitalization; and 5) the role of religious or spiritual guidelines as an influence on patient preferences about medical care.Conclusion(s)dGOCC after severe ischemic stroke infrequently include information about a patient's or family's religion, spirituality, or faith. Among the few patients for which religion, faith, or spiritual beliefs were documented as being discussed, there was limited information about the implications of the role religion, faith, or spiritual beliefs played in the patient's medical care.ImpactThe results of this study indicate there are missed opportunities to discuss religion, faith, or spiritual beliefs with patients who have experienced an acute, unexpected medical event.KeywordsCommunication and prognostication/Psychosocial support

BACKGROUND:When a patient is disabled after stroke, they require both emotional support and medical management and may require the assistance of a caregiver. Given the often-sudden onset of disability and the complex challenges related to caring for someone after stroke, caregivers can experience a heavy burden. Caregiver burden negatively affects quality of care, quality of life, and physical and psychological health. The impact of gender on caregiver burden has been in many other conditions; however, the association has not yet been thoroughly assessed in stroke. OBJECTIVE:The aim of this paper is to define caregiver burden, discuss how it is assessed, discuss unique aspects of burden for stroke caregivers, and determine the impact of sex and gender on stroke caregiver role and burden. METHODS:A narrative review was performed to synthesize the available literature and explore how the role of sex and gender impact caregiving for patients who have suffered stroke and whether sex and gender of the caregiver contribute to caregiver burden r. RESULTS:Review of the available literature suggests that sex and gender significantly impact caregiving burden following stroke dipropionately affecting women. CONCLUSIONS:Caregiving for patients who have suffered stroke is often provided by women both inside the home and when patients are within institutions. Women who serve as caregivers to stroke patients may be at higher risk of experiencing burden and its negative effects, including emotional strain, anxiety, and/or depression. More research is needed to determine the best ways to provide support for women who act as caregivers for stroke patients to mitigate caregiver burden.

Code status orders in hospitalized patients guide urgent medical decisions. Inconsistent terminology and treatment options contribute to varied interpretations. To compare two code status order options, traditional (three option) and modified to include additional care options (four option). Prospective, randomized, cross-sectional survey conducted on February–March 2020. Participants were provided with six clinical scenarios and randomly assigned to the three or four option code status order. In three scenarios, participants determined the most appropriate code status. Three scenarios provided clinical details and code status and respondents were asked whether they would provide a particular intervention. This study was conducted at three urban, academic hospitals. Clinicians who routinely utilize code status orders. Of 4006 participants eligible, 549 (14

Background and ObjectivesThe distinct illness trajectory after acute ischemic stroke demands a better understanding of the utilization of palliative care consultations (PCC) for this patient cohort. This study sought to determine the prevalence, predictors, and outcomes associated with PCC for patients hospitalized with severe ischemic stroke.MethodsThis multicenter cohort study was conducted at four hospitals (2 comprehensive and 2 primary stroke centers) between January, 2016 and December, 2019. We included all patients with a discharge diagnosis of ischemic stroke and an initial National Institutes of Health Stroke Scale (NIHSS) of 10 or greater. We compared patient sociodemographic, clinical and care characteristics as well as hospital outcomes between patients who did and did not receive PCC.ResultsThe study included 1297 patients hospitalized with severe ischemic stroke. PCC occurred for 20% of all patients and this proportion varied across institutions from 11.9% to 43%. Less than half (43%) of patients who died in the hospital. In multivaraible analysis, PCC was less likely in female patients (OR .76, 95% CI .59, .99, P=0.04) but more likely in patients with higher NIHSS (OR1.95, 95% CI 1,13, 3.37, P=0.02). Patients with PCC had higher rates of moving to a plan focused on comfort measures (CMO) (P<0.01) and removal of artificial nutrition as part of a move to CMO (P<0.01). In a sub analysis of patients who died in the hospital and received PCC, patients who died on or before hospital day 3 were less likely to receive PCC than patients who died on or after hospital day 4 (24% v. 51%) (P=<0.01).ConclusionsMost patients with severe stroke do not receive PCC, even among those who experience in-hospital death. The results of this study indicate there are missed opportunities for PCC to help reduce suffering after severe stroke.