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Post CCT Fellowship in Palliative Renal Medicine

Background and case of need

With the increasing number of patients on renal replacement therapy (RRT), the treatment increasingly caters to a more elderly, co-morbid population. In 2010, the median age of a patient starting RRT in the UK was 64.9and peripheral vascular diseases and ischaemic heart disease affect between 15 and 29% of those aged 65-74. The unadjusted one year survival for a patient on RRT is 83.8%; however the five year survival for a patient starting dialysis aged over 65 is 29%1. Of the four most common cancers (prostate, lung, colorectal and breast) only lung cancer compares less favourably2. In addition, the symptom burden for a patient on dialysis is similar to the profile of a patient with metastatic cancer3.

Several key documents have highlighted the need to tailor care more appropriately towards the supportive needs of renal patients4-7.

Several centres across the UK have established that offering conservative kidney management as a positive choice results in a significant uptake, particularly amongst patients who are least likely to do well on dialysis such as those over 79 years with multiple co-morbidities and poor performance status8,9.

Apart from the high tariff for dialysis the personal cost for patients is significant with haemodialysis patients likely to spend half of their lives in hospital and 6% of patients dying in the first three months of dialysis1.

In order to provide a high quality service to meet the complex needs of this growing group of patients, physicians need a broad range of knowledge and skills spanning nephrology and palliative medicine. The anxieties of doctors prescribing in renal failure is well documented but so too is the poor management of symptoms such as pain by nephrologists. At present, nephrology training covers palliative care to a very basic level, and palliative medicine training covers some basic aspects of nephrology. However, neither curriculum provides the detailed knowledge and skills required. A palliative renal physician would enhance the care of these patients, bridging the gap between the specialties and should be attractive to employers.

We propose a novel approach to a post CCT Fellowship that could take a specialist with a CCT in either renal or palliative medicine and provide the necessary training and experience to deliver high quality palliative renal medicine. Two outline programmes would be made available to cater for physicians from each “host” specialty, modified to suit individual needs. The fellowship would be completed in 12 months.

Aims of the Post-CCT Fellowship in Palliative Renal Medicine

  1. To develop physicians with the knowledge, skills and behaviours to manage patients with stage 4-5 CKD and complex co-morbidities
  2. To routinely provide patients with an informed choice about high quality palliative renal care in place of RRT to enable shared decision-making
  3. To provide patients with high quality symptom management whilst receiving RRT
  4. To provide patients with ongoing choice about when/whether to stop RRT when it becomes too burdensome to continue and to manage the transition to end-of-life care on stopping RRT
  5. To act as a resource for teaching/training nephrology and palliative care colleagues on palliative renal medicine
  6. To act as a resource in managing and planning renal palliative care services.

Organisation and supervision

Each Fellow will have supervision from both a palliative and renal medicine consultant who will act as educational guides. The lead guide will be agreed at the outset of the programme. It is expected that the Fellow will meet with their guides at the beginning of the Fellowship to set a formal personal development plan (PDP). This will be reviewed at the mid-point and end of the Fellowship.

Common elements of the Fellowship programme that apply to CCT holders in renal and palliative medicine

Leadership

Fellows will be expected to demonstrate that they have negotiated learning experiences to improve their effectiveness in leadership and have further developed their skills, knowledge and behaviour to:

  • manage and develop self and personal qualities
  • work with others, develop and maintain relationships
  • build teams and enable successful outcomes
  • develop networks outside/complementary to medicine
  • manage and use resources effectively
  • facilitate change
  • plan appropriately and achieve results to improve health care services and patient safety
  • set direction and communicate the vision.

Management

Fellows will be expected to demonstrate that they have negotiated learning experiences to improve their effectiveness in management and have further developed their skills, knowledge and behaviour to:

  • develop and expand awareness of self and others in the context of a constantly changing NHS and health care system
  • understand the pressures on and changes occurring in the NHS and health care system
  • understand the allocation of resources and financial governance in the NHS
  • understand the interdependency of personal, organisational and NHS goals
  • develop the ability to contribute effectively to strategic planning and deliver effective operational management to achieve strategic goals
  • develop effective operational management skills according to organisational guidance/policy (eg appraisal, interview and selection, disciplinary processes, complaints, clinical governance for the organisation)
  • develop personal skills:
  • Team working
  • Motivating
  • Influencing
  • Negotiating
  • Delegating
  • Managing time (self and others)
  • acquire skills needed to enable successful recruitment, interview and selection of staff

Education

Fellows will be expected to demonstrate that they have negotiated learning experiences to improve their effectiveness in an education role and have further developed their skills, knowledge and behaviour to:

  • broaden experience of teaching and understanding of work-based learning
  • Locally
  • Regionally
  • University (undergraduate and postgraduate medicine)
  • develop links with other organisations, including:
  • Deaneries
  • GMC
  • University (undergraduate and postgraduate medicine)
  • develop self-awareness to understand your own learning needs and implement strategies and mechanisms to address these, including active participation in:
  • CPD
  • Appraisal
  • Revalidation
  • acquire skills needed to increase awareness of the role that management of learning can have within the health care setting and develop the ability to apply the learning theory to the clinical context, including successfully completing:
  • Supervisor’s course
  • Educational supervision course

Research

Fellows will be expected to demonstrate that they have negotiated learning experiences to improve their effectiveness in a research role and have further developed their knowledge, skills and behaviour to:

  • actively participate in online and local opportunities to meet and learn from established researchers
  • develop skills in research methodology
  • develop critical appraisal skills

Post CCT Fellowship from Renal Medicine

Knowledge

  • Symptom prevalence in patients with stage 4-5 CKD
  • Detailed pharmacological knowledge of symptom management in renal disease
  • Non-pharmacological methods of symptom management
  • Knowledge of the MDT from a palliative care perspective and the benefit it can bring to the patient’s care.
  • Knowledge of community services and how they can be mobilised to support patients towards the end of life
  • Knowledge of systems used in primary care to manage such patients, such as end of life care registers, the Gold Standards Framework and how to access them
  • Knowledge of the limitations of community-based services
  • Understanding of important ethical concepts such as withdrawing and withholding treatment, advance care planning
  • Know about the role of the hospicefor inpatient and outpatient care
  • Know about the role of the hospital/hospice chaplaincy service and how to refer patients
  • Know about risk factors in bereavement, services available and how to refer.

Skills/behaviours

  • Ability to tailor a consult towards symptom assessment, management and control
  • To develop advanced communication skills
  • Ability and willingness to engage patients in shared decision making about treatment choices
  • Ability to conduct a detailed holistic assessment including physical, psychological, social and spiritual domains
  • Willingness to refer to other members of the multi-professional team
  • Ability to weigh up ethically complex situations and provide advice/direction to colleagues when faced with difficult clinical decisions

Experience

  • Opportunities for networking with palliative care colleagues and developing contacts.
  • Working with hospice inpatient and community services
  • Experience of a specialist palliative care (hospice) MDT meeting
  • Working with hospital specialist palliative care team
  • Visits to primary care, Gold Standards Framework meetings and home visits
  • Visits with District Nurses

Post CCT Fellowship from Palliative Medicine

Knowledge

  • Knowledge of the various degrees of renal impairment and their significance
  • Knowledge of different forms of dialysis, their benefits and burdens
  • Knowledge of the use of dialysis in symptom management and its place in palliation
  • Knowledge of the process of dialysis and transplantation
  • Detailed knowledge of pharmacology, especially drug handling in renal failure, cardiovascular disease and consequent polypharmacy
  • Detailed knowledge of the drug treatments available to a patient at various stages of chronic kidney disease and of how to modify prescribing accordingly
  • Knowledge of the role of the pre-dialysis team and the conservative kidney management clinic and their interface with primary and specialist palliative care.
  • Knowledge of the prevalence of symptoms in patients with stage 4 CKD and their management
  • Knowledge about the use of specific palliative treatments, such as iron and erythropoietin for symptomatic management of anaemia.
  • Knowledge of the diagnosis and management of common co-existing conditions such as diabetes, COPD

Skills/behaviours

  • Ability and willingness to discuss treatment and care options with patients considering withdrawing from dialysis, embracing shared decision making with patients
  • Appreciation of thecomplexities of patient withdrawal from treatment, including physical, psychological, social and spiritual aspects
  • Prescribing in different stages of renal failure
  • Palliative management of patients with multiple co-morbidities and the resultant polypharmacy

Experience

  • Opportunities for networking with nephrology colleagues and developing contacts
  • Undertaking joint clinics and ward rounds with nephrology colleagues
  • Exposure to dialysis units and their MDTs
  • Talking with patients on haemo and peritoneal dialysis about the practicalities of treatment
  • Experience in transplantation, especially in decision-making when a transplant fails
  • Experience of decision-making for patient referrals with acute kidney injury

Outcomes and Assessment

By the end of the Fellowship, the physician will be able to deliver high quality palliative renal care to patients who choose conservative management, to symptomatic patients on or awaiting dialysis, and manage patients and their families who withdraw from dialysis.They will act as an interface between the two specialities to improve communication and appropriate management of the ever increasing elderly population with multiple co-morbidities They will be equipped to advise on symptomatic management of patients and support them in the community without admission to hospital where possible and to help facilitate timely discharges for those whose preferred place of care is at home.

The success criteria for the Fellowship will be agreed by the Fellow, educational guides and employing Trust at the outset and will include as a minimum:

  • 360degree feedback of the Fellow
  • reflective practice using the resource on
  • a written report to both SACs from the Fellow and educational guidesincluding aspects of the post that you may do differently in future
  • a presentation to the Trust renal and palliative care departments
  • clinical audit

Authors and affiliations

Dr Fiona Hicks, Consultant in Palliative Medicine Leeds Teaching Hospitals Trust, chair SAC in Palliative Medicine

Dr Lynne Russon, Consultant in Palliative Medicine, Sue Ryder Wheatfields

Dr Shareen Siddiqi, Consultant Nephrologist Sheffield Teaching Hospitals Foundation Trust

Dr Patricia Brayden, Consultant in Palliative Medicine and Director of Medical Services St Catherine's Hospice, West Sussex

Prof Edwina Brown, Consultant Nephrologist Imperial College

Dr Lucy Smyth, Consultant Nephrologist, Royal Devon and Exeter NHS Foundation Trust

References

1. Caskey F, Dawnay A, Farrington K, Feest T, Fogarty D, Inward C, Tomson CRV: UK Renal Registry Report 2010. Bristol, UK: UK Renal Registry, 2011

2. Office of National Statistics (ONS) Cancer Incidence and Mortality in the UK, 2008-10. Accessed 31/05/2013

3. Saini, T., F. E. Murtagh, et al. (2006).Comparative pilot study of symptoms and quality of life in cancer patients and patients with end stage renal disease. Palliat Med 20(6): 631-636

4. Gomm, S. and K. Farringdon (2009). End of Life Care in Advanced Kidney Disease: A Framework for Implementation. N. E. o. L. P. N. K. Care. Suffolk, National End of Life Care Programme.

5. GMC (2010). Treatment and care towards the end of life: good practice in decision making. London, UK.

6. Dixon, J. J., J. E. Marsh, et al. (2010). "Palliative care: A year on the Liverpool Care Pathway in renal medicine." British Journal of Renal Medicine 15(1): 4-7.

7.The Marie Curie Palliative Care Institute (2008). Guidelines for LCP Prescribing in Advanced Chronic Kidney Disease. Liverpool.

8. Hussain J, Mooney A and Russon L. Comparison of survival analysis and palliative care involvement in patients aged over 70 years choosing conservative management or renal replacement therapy in advanced chronic kidney disease. PalliatMed June 2013 Don't have full reference yet.

9. Chadna SM, Da Silve-Gane M, Marshall C et al. Survival of elderly patients with stage 5 CKD: comparison of conservative management and renal replacement therapy. Nephrol Dial Transplant 2011; 26(5): 1608-1614

Post CCT Fellowship in Palliative Renal Medicine