Patients with end-stage kidney disease (ESKD) on hemodialysis have limited life expectancy, yet their palliative care needs often go unmet. The aim of this study was to identify barriers and facilitators for implementation of “Shared Decision Making and Renal Supportive Care” (SDM-RSC), an intervention to improve advance care planning (ACP) for patients with ESKD on hemodialysis. The Consolidated Framework for Implementation Research (CFIR) was the organizing framework for this study. CFIR is a theory-based implementation framework consisting of five domains (Intervention Characteristics, Inner Setting, Outer Setting, Characteristics of Individuals, and Process), each of which has associated constructs. Potential barriers and facilitators to implementation of the SDM-RSC intervention were identified through observation of study procedures, surveys of social workers nephrologists, study participants, and family members, and assessment of intervention fidelity. Twenty-nine nephrologists and 24 social workers, representing 18 outpatient dialysis units in Massachusetts (n = 10) and New Mexico (n = 8), were trained to conduct SDM-RSC intervention sessions. A total of 102 of 125 patient enrolled in the study received the intervention; 40 had family members present. Potential barriers and facilitators to implementation of the SDM-RSC intervention were identified in each of the five CFIR domains. Barriers included complexity of the intervention; challenges to meeting with patients on non-dialysis days; difficulties scheduling intervention sessions due to nephrologists’ and social workers’ caseloads; perceived need for local policy change regarding ACP; perceived need for additional ACP training for social workers and nephrologists; and lack of endorsement of the intervention by some staff members. Facilitators included: training for social workers, national dialysis chain leadership engagement and the institution of social worker/nephrologist clinic champions. ACP for patients on hemodialysis can have a positive impact on end-of-life outcomes for patients and their families but does not take place routinely. The barriers to effective implementation of interventions to improve ACP identified in this study might be addressed by: adapting the intervention for local contexts with input from clinicians, dialysis staff, patients and families; providing nephrologists and social workers additional training prior to delivering the intervention; and developing policy that routinizes ACP for hemodialysis patients. Clinicaltrials.gov NCT02405312. Registered 04/01/2015.

中文翻译：

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血液透析患者的预先护理计划：一项实施研究

血液透析终末期肾脏病（ESKD）患者的预期寿命有限，但是他们对姑息治疗的需求往往得不到满足。这项研究的目的是确定实施“共享决策和肾脏支持治疗”（SDM-RSC）的障碍和促进因素，这是一项改善血液透析ESKD患者的预先护理计划（ACP）的干预措施。实施研究综合框架（CFIR）是本研究的组织框架。CFIR是一个基于理论的实施框架，由五个领域（干预特征，内部设置，外部设置，个人特征和过程）组成，每个领域都有相关的构造。通过观察研究程序，确定了实施SDM-RSC干预的潜在障碍和促进者，对社会工作者肾脏病学家，研究参与者和家庭成员进行的调查，以及干预保真度的评估。培训了代表马萨诸塞州（n = 10）和新墨西哥州（n = 8）的18个门诊透析单位的29位肾脏科医生和24名社会工作者，进行了SDM-RSC干预会议。该研究招募的125位患者中，共有102位接受了干预。40位家庭成员在场。在五个CFIR域中的每个域中，都发现了实施SDM-RSC干预的潜在障碍和促进者。障碍包括干预的复杂性；在非透析日与患者会面的挑战；由于肾脏科医生和社会工作者的病情负荷，难以安排干预会议；认为需要对ACP进行本地政策更改；认为需要对社会工作者和肾脏病医生进行额外的ACP培训；并且缺乏某些工作人员的干预。主持人包括：社会工作者培训，国家透析链领导参与以及社会工作者/肾脏病医生诊所冠军机构。接受血液透析的患者的ACP可能会对患者及其家人的生命结局产生积极影响，但这种情况并非常规发生。在本研究中确定的有效实施改善ACP的干预措施的障碍可以通过以下方式解决：通过临床医生，透析人员，患者和家属的意见使干预措施适应当地情况。在进行干预之前，为肾病医生和社会工作者提供额外的培训；并制定对血液透析患者常规化ACP的政策。Clinicaltrials.gov NCT02405312。注册于2015年4月1日。