Necessity of Advance Care Planning in a Highly Aging CKD Society

Background: The patients with CKD-5 or 5D have been aging throughout the world especially in Japan. According to the latest data from Japanese Society for Dialysis Therapy, the average age of CKD-5D patients was 71.6 years in incidence and 70.0 years in prevalence. The distribution of patients older than 80 years was 32.5% in incidence and 24.6% in prevalence. In Japan greater than 95% of the patients are treated by in-center hemodialysis (HD) and this tendency became more significant through aging of the patients. We have been wondering whether the priorities of the elder patients have been properly treated under this facility-based dialysis care. Methods: We organized three working groups to set up ACP; Ground Design (GD) group, Advance Directive (AD) group and Conservative Kidney Management (CKM) group. GD group promoted ACP to the patients and the staffs. AD group composed an original well-living note called “I Hope Note” and tried to monitor the patients’ priorities. CKM group composed three booklets; Guidebook to choose CKM, Guide book to treat your symptom in CKM and Manual of Palliative Care Drug Therapy. Each staff member collected “ACP pieces” related to the patient's priorities and recorded them in the electronic medical record system with the hashtag “ACP.” Results: “ACP pieces” greater than 2,000 were collected in 2 years after we started ACP for CKD patients. 58.1% of them were collected by nurses, 12.5% by physicians, 11.0% by dietitians, 10.0% by clinical engineers, 6.3% by medical social workers, 2.0% by the physical therapists, and 0.1% by pharmacologists. The possession rate of “I HOPE Note” was 63%, and among those who possessed them, approximately 37% had written something on them. The most common reason for writing nothing was “it's too early for me.” Some patients expressed hesitation in thinking about their own future death. Three patients undergoing in-center dialysis in the terminal stage chose CKM and ended their lives at home in cooperation with their family doctors. Conclusion: In Japan, the in-center HD model is highly developed, and this system has undoubtedly saved a lot of lives of patients with end-stage kidney failure. However, this model does not guarantee a good QOL for each dialysis patient, and it remains questionable whether the system respects their priorities. We should know their priorities first, and set up the proper therapeutic and care plan to each patient.