Advance Care Planning Coaching in CKD Clinics: A Pragmatic Randomized Clinical Trial.

Rationale and objective Although guidelines recommend more and earlier advance care planning (ACP) for patients with chronic kidney disease (CKD), scant evidence exists to guide incorporation of ACP into clinical practice for patients not yet requiring maintenance dialysis. Involving nephrology team members in addition to primary care providers in this important patient-centered process may increase its accessibility. Our objective was to examine the effect of coaching implemented in CKD clinics on patient engagement with ACP. Study design Multicenter, pragmatic randomized control trial. Setting & participants Three CKD clinics in different states participated. Eligible patients were 55 years or older, had stage 3-5 CKD, and were English speaking. 273 patients consented to participate, 254 were included in analysis. Intervention Nurses or social workers with experience in nephrology or palliative care delivered individualized in-person ACP sessions. The enhanced control group was given Make Your Wishes About You (MY WAY) education materials and was verbally encouraged to bring their completed advance directives to the clinic. Outcomes Primary outcome measures were scores on a 45-point ACP engagement scale at 14 weeks and a documented advance directive or portable medical order at 16 weeks post-enrollment. Results Among 254 participants analyzed, 46.5% were 65-74 years of age and 54% had CKD stage 3. Coached patients scored 1.9 points higher at 14 weeks on the ACP engagement scale (β = 1.87; CI: 0.13-3.64) adjusted for baseline score and site. Overall, 32.8% of intervention patients (41 of 125) had an advance directive compared to 17.8% (23 of 129) of patients in the comparison group. In a site-adjusted multivariable model, coached patients were 79% more likely to have a documented advance directive or portable medical order (adjusted risk ratio = 1.79; 95% CI: 1.18-2.72), with the impact principally evident at only one study site. Limitations Small number of study sites and possible unrepresentativeness of the broader CKD population by study participants. Conclusions and relevance Individualized coaching may be effective in enhancing ACP but its impact may be influenced by the healthcare environment where it is delivered.