Family Members' Understanding of the End-of-Life Wishes of People Undergoing Maintenance Dialysis.

BACKGROUND AND OBJECTIVES: People receiving maintenance dialysis must often rely on family members and other close persons to make critical treatment decisions toward the end of life. Contemporary data on family members' understanding of the end-of-life wishes of members of this population are lacking. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Among 172 family members of people undergoing maintenance dialysis, we ascertained their level of involvement in the patient's care and prior discussions about care preferences. We also compared patient and family member responses to questions about end-of-life care using percentage agreement and the κ-statistic. RESULTS: The mean (SD) age of the 172 enrolled family members was 55 (±17) years, 136 (79%) were women, and 43 (25%) were Black individuals. Sixty-seven (39%) family members were spouses or partners of enrolled patients. A total of 137 (80%) family members had spoken with the patient about whom they would want to make medical decisions, 108 (63%) had spoken with the patient about their treatment preferences, 47 (27%) had spoken with the patient about stopping dialysis, and 56 (33%) had spoken with the patient about hospice. Agreement between patient and family member responses was highest for the question about whether the patient would want cardiopulmonary resuscitation (percentage agreement 83%, κ=0.31), and was substantially lower for questions about a range of other aspects of end-of-life care, including preference for mechanical ventilation (62%, 0.21), values around life prolongation versus comfort (45%, 0.13), preferred place of death (58%, 0.07), preferred decisional role (54%, 0.15), and prognostic expectations (38%, 0.15). CONCLUSIONS: Most surveyed family members reported they had spoken with the patient about their end-of-life preferences but not about stopping dialysis or hospice. Although family members had a fair understanding of patients' cardiopulmonary resuscitation preferences, most lacked a detailed understanding of their perspectives on other aspects of end-of-life care.

Frequency and Severity of Moral Distress in Nephrology Fellows: A National Survey.

INTRODUCTION: Moral distress is a negative affective response to a situation in which one is compelled to act in a way that conflicts with one's values. Little is known about the workplace scenarios that elicit moral distress in nephrology fellows. METHODS: We sent a moral distress survey to 148 nephrology fellowship directors with a request to forward it to their fellows. Using a 5-point (0-4) scale, fellows rated both the frequency (never to very frequently) and severity (not at all disturbing to very disturbing) of commonly encountered workplace scenarios. Ratings of ≥3 were used to define "frequent" and "moderate-to-severe" moral distress. RESULTS: The survey was forwarded by 64 fellowship directors to 386 fellows, 142 of whom (37%) responded. Their mean age was 33 ± 3.6 years and 43% were female. The scenarios that most commonly elicited moderate to severe moral distress were initiating dialysis in situations that the fellow considered futile (77%), continuing dialysis in a hopelessly ill patient (81%) and carrying a high patient census (75%), and observing other providers giving overly optimistic descriptions of the benefits of dialysis (64%). Approximately 27% had considered quitting fellowship during training, including 9% at the time of survey completion. CONCLUSION: A substantial majority of nephrology trainees experienced moral distress of moderate to severe intensity, mainly related to the futile treatment of hopelessly ill patients. Efforts to reduce moral distress in trainees are required.

A Multi-Factorial Assessment of Functional Human Autistic Spectrum Brain Network Analysis.

The variability of the results obtained by the statistical analysis of functional human brain networks depend on multiple factors such as: the source of the fMRI data, the brain parcellations, the graph theory measures, and the threshold values applied to the functional connectivity matrices to obtain adjacency matrices of sparse graphs. Therefore, the brain network used for down-stream analysis is heavily dependent on the methods that are applied to the fMRI data to obtain and analyze such networks. In this paper we present the preliminary results of a multi-factorial assessment of the statistical analysis of functional human brain networks. The assessment was performed in the functional human brain networks obtained from the resting state fMRI data of ten imaging sites provided by the Autism Brain Imaging Data Exchange (ABIDE) preprocessed functional magnetic resonance database, with six different functional brain parcellations, six different graph theory measures, and three different threshold values applied to the corresponding connectivity matrices to obtain sparse graphs. The statistical analysis to detect differences between the networks representing autism and control subjects were performed with four different statistical methods, using the p-values to determine the levels of significance of the analysis. Our main results show a strong dependence of functional human brain networks statistical analysis on the brain parcellations, and on the graph theory measures. Our results further show that the results of these analysis are less dependent on the statistical tests methods and on the threshold values of the sparse graphs for all practical purposes. An additional result is that the levels of significance of the statistical tests obtained for data provided by individual sites were much higher than the global levels of significance obtained by averaging the results of all the sites, implying that the best results on the analysis of functional human brain networks are obtained when the source of the fMRI data is the same for all the data. Since reproducibility and reliability of functional brain network statistical analysis is strongly dependent on the graphs obtained from fMRI data; our expectation is that the novel results presented in this paper would further help researchers in this field to develop methods that are reliable and reproducible.

Outcomes of In-Hospital Cardiopulmonary Resuscitation in Patients with CKD.

BACKGROUND AND OBJECTIVES: Advance care planning, including code/resuscitation status discussion, is an essential part of the medical care of patients with CKD. There is little information on the outcomes of cardiopulmonary resuscitation in these patients. We aimed to measure cardiopulmonary resuscitation outcomes in these patients. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Our study is observational in nature. We compared the following cardiopulmonary resuscitation-related outcomes in patients with CKD with those in the general population by using the Nationwide Inpatient Sample (2005-2011): (1) survival to hospital discharge, (2) discharge destination, and (3) length of hospital stay. All of the patients were 18 years old or older. RESULTS: During the study period, 71,961 patients with CKD underwent in-hospital cardiopulmonary resuscitation compared with 323,620 patients from the general population. Unadjusted in-hospital mortality rates were higher in patients with CKD (75% versus 72%; P<0.001) on univariate analysis. After adjusting for age, sex, and potential confounders, patients with CKD had higher odds of mortality (odds ratio, 1.24; 95% confidence interval, 1.11 to 1.34; P≤0.001) and length of stay (odds ratio, 1.11; 95% confidence interval, 1.07 to 1.15; P=0.001). Hospitalization charges were also greater in patients with CKD. There was no overall difference in postcardiopulmonary resuscitation nursing home placement between the two groups. In a separate subanalysis of patients ≥75 years old with CKD, higher odds of in-hospital mortality were also seen in the patients with CKD (odds ratio, 1.10; 95% confidence interval, 1.02 to 1.17; P=0.01). CONCLUSIONS: In conclusion, we observed slightly higher in-hospital mortality in patients with CKD undergoing in-hospital cardiopulmonary resuscitation.

Outcomes of In-Hospital Cardiopulmonary Resuscitation in Maintenance Dialysis Patients.

Outcomes of cardiopulmonary resuscitation (CPR) in hospitalized patients with ESRD requiring maintenance dialysis are unknown. Outcomes of in-hospital CPR in these patients were compared with outcomes in the general population using data from the Nationwide Inpatient Sample (NIS; 2005-2011). The study population included all adults (≥ 18 years old) from the general population and those with a history of ESRD. Baseline characteristics, in-hospital complications, and discharge outcomes were compared between the two groups. The effects of in-hospital CPR on mortality, length of stay, hospitalization charges, and discharge destination were analyzed. Yearly national trends in survival, discharge to home, and length of stay were also examined using the Cochran-Armitage trend test. During the study period, 56,069 patients with ESRD underwent in-hospital CPR compared with 323,620 patients from the general population. Unadjusted in-hospital mortality rates were higher in patients with ESRD (73.9% versus 71.8%, P<0.001) on univariate analysis. After adjusting for age, gender, and potential confounders, patients with ESRD had higher odds of mortality (odds ratio, 1.24; 95% confidence interval, 1.11 to 1.3; P<0.001). Survival after CPR improved in the year 2011 compared with 2005 (31% versus 21%, P<0.001). Multivariate analysis also revealed that a greater proportion of patients with ESRD who survived were discharged to skilled nursing facilities. In conclusion, outcomes after in-hospital CPR are improving in patients with ESRD but remain worse than outcomes in the general population. Patients with ESRD who survive are more likely to be discharged to nursing homes.

Downscaled climate change projections with uncertainty assessment over India using a high resolution multi-model approach.

This study presents the possible regional climate change over South Asia with a focus over India as simulated by three very high resolution regional climate models (RCMs). One of the most striking results is a robust increase in monsoon precipitation by the end of the 21st century but regional differences in strength. First the ability of RCMs to simulate the monsoon climate is analyzed. For this purpose all three RCMs are forced with ECMWF reanalysis data for the period 1989-2008 at a horizontal resolution of ~25 km. The results are compared against independent observations. In order to simulate future climate the models are driven by lateral boundary conditions from two global climate models (GCMs: ECHAM5-MPIOM and HadCM3) using the SRES A1B scenario, except for one RCM, which only used data from one GCM. The results are presented for the full transient simulation period 1970-2099 and also for several time slices. The analysis concentrates on precipitation and temperature over land. All models show a clear signal of gradually wide-spread warming throughout the 21st century. The ensemble-mean warming over India is 1.5°C at the end of 2050, whereas it is 3.9°C at the end of century with respect to 1970-1999. The pattern of projected precipitation changes shows considerable spatial variability, with an increase in precipitation over the peninsular of India and coastal areas and, either no change or decrease further inland. From the analysis of a larger ensemble of global climate models using the A1B scenario a wide spread warming (~3.2°C) and an overall increase (~8.5%) in mean monsoon precipitation by the end of the 21st century is very likely. The influence of the driving GCM on the projected precipitation change simulated with each RCM is as strong as the variability among the RCMs driven with one.