Early integration of palliative care in outpatient nephrology: exploring healthcare professionals' knowledge, attitudes, and communication practices - an exploratory multi-methods study.

Abstract

Background: Patients with advanced kidney disease often experience high symptom burden and complex illness trajectories, highlighting the importance of integrating palliative care into nephrology. However, palliative care remains insufficiently integrated into routine care within nephrology outpatient centers. This study explored healthcare professionals' (HCPs) perspectives on palliative care integration, including knowledge and confidence in identifying patients with palliative care needs as well as perceived barriers and facilitators to implementation.

Methods: An explorative multi-methods study was conducted as part of a project aiming to implement a minimally invasive intervention in nephrology outpatient centers in Germany (MINI-Neph). HCPs from participating centers received a one-hour training introducing palliative care in nephrology, communication strategies for emotionally challenging situations, and using two validated tools for identifying patients with palliative care needs: the Surprise Question (SQ) and the Supportive and Palliative Care Indicators Tool (SPICT-DE). Data were collected through an online survey, free-text responses and semi-structured interviews with HCPs and analyzed using descriptive statistics and qualitative content analysis, respectively.

Results: Five nephrology outpatient centers located in different regions across Germany were involved in the MINI-Neph-Study. A total of 52 HCPs participated; most were female (82.7%), with the largest age groups being 31-40 years (30.8%) and 51-60 years (28.8%). Roles included nurses (57.7%), medical assistants (25.0%), and nephrologists (15.4%). While most participants recognized the relevance of integrating palliative care into nephrology, only about half reported confidence in identifying patients with palliative care needs in their presumed last year of life. Communication about patients' preferences regarding care, treatment decisions, and advance directives occurred inconsistently, while discussions about preferred place of care or death were reported less frequently. Knowledge of legal aspects of end-of-life care and confidence in organizing referrals to palliative care services were limited. Additionally, 13 qualitative interviews were conducted with HCPs from three nephrology outpatient centers (2 nephrologists, 2 medical assistants, and 8 nurses). The interviews highlighted the complex and dynamic trajectories of patients with advanced kidney disease. Conversations about serious illness and care goals were mostly reactive, while interprofessional communication and collaboration with external providers remained limited. Training increased awareness of palliative care needs, but structural barriers such as time pressure and a treatment-focused culture hindered consistent implementation.

Conclusions: Early integration of palliative care in outpatient nephrology is valued by HCPs, while confidence in identifying palliative care needs and communicating about end-of-life issues was inconsistent, and palliative care remains predominantly reactive in routine care. The MINI approach may support more systematic and proactive care. More proactive care may require protected time, structured communication, clear responsibilities, and established communication pathways.