Advance care planning with patients who have end-stage kidney disease: a systematic realist review: Advance care planning in end-stage kidney disease

Context: Patients with end-stage kidney disease have a high mortality rate and disease burden. Despite this, many do not speak with healthcare professionals about end-of-life issues. Advance care planning is recommended in this context but is complex and challenging. We carried out a realist review to identify factors affecting its implementation.
Objectives:
1. To identify implementation theories.
2. To identify factors that help or hinder implementation.
3. To develop theory on how the intervention may work.
Methods: Systematic realist review, searching seven electronic databases: Medline, Embase, CINAHL, PsychInfo, Cochrane Library, Google Scholar and Science Direct.
Results: 62 papers were included in the review.
Conclusion: We identified two intervention stages. 1. Training for healthcare professionals that addresses concerns, optimises skills, and clarifies processes. 2. Use of documentation and processes that are simple, individually tailored, culturally appropriate, and involve surrogates.
These processes work as patients develop trust in professionals, participate in discussions, and clarify values and beliefs about their condition. This leads to greater congruence between patient and surrogate; increased quality of communication between patients and professionals; and increased completion of advance directives.
Advance care planning is hindered by lack of training; administrative complexities; pressures of routine care; patients overestimating life-expectancy; and when patients, family, and/or clinical staff are reluctant to initiate discussions. It is more likely to succeed where organisations treat it as core business; when the process is culturally appropriate and takes account of patient perceptions; and when patients are willing to consider death and dying with suitably trained staff.