Thisworksheetwillhelpyouactivielyengagewiththeinformationsoyoucanbetterretainandlearnnewskills.Downloadandprintthisworksheetandrecordyouranswersandreflectionsaboutconservativecareasyouwatchthevideosandworkthroughtheexercises.

Module1:Whyconservativecare?Q1:Onaveragehowlongdoyouthinkapersonwithstage5CKD(estimatedfunctionlessthan15)cansurvivewithoutdialysis?

A.Days

B.Weeks

C.Months

D.Years

Q2:Comparedtodialysis,howwouldCCimpactthefollowingfactors?Writedownwhetherthesefactorswouldincrease,decreaseornotchange? Increase Decrease NochangeTimeinthehospital:

Qualityoflife:

Physicalsymptoms:

Endoflifeathome:

Hospiceservices:

Q3:Writedown2prognosticfactorsthatwouldlimitsurvivalwithdialysisforWilliamandRita:William:1.

2.

Rita:1.

2.

Q4:Writethreepotentialsideeffectsofdialysisthatmaybeburdensomeforthesepatients:Q5:HowlongdoyouthinkapersonlikeWilliamcanliveondialysis?Wrapup:CheckyouranswersforQ1and2attheendofmodule1!Reflectionquestions:WhatsurprisedyoumostaboutConservativeCare?What’sonethingyouwilldodifferentlybasedonthismodule?

Module2:IdentifywhobenefitsQ1:Applythesurprisequestion(Wouldyoubesurprisedifthispatientdiedinthenextyear?)toWilliamandRita’scase.

Q2:Usingthe6-monthESRDintegratedprognosiscalculator(https://qxmd.com/calculate/calculator_135/6-month-mortality-on-hd),calculatethe6monthsurvivalforWilliamandRita:

William’sestimatedsurvivalondialysisat6months:

Rita’sestimatedsurvivalondialysisat6months:

Prognosisexercisetoputyourskillsintopractice:

Chooseapatientyouarescheduledtoseeinclinicwhomaybenefitfromconservativecare.

1. Calculatethispatient’smortalityriskusingthe6monthintegratedprognostictool.

2. Duringthevisit,assesshowtheirfunctionandpresenceofgeriatricsyndromesusingoneortwoofthequestionstaughtinthemodule.Hereareexamplequestions:

“Tellmewhatyourtypicaldayathomeislike.”

“Howhasyourabilitytodothethingsyouwanttodochangedinthepastyear?”

“Doyouhavedifficultyorrequireassistancewithanyofthefollowing?:bathing,dressing,toileting,transfers,grooming,eating”

“Whatdoyoufindmostchallengingaboutcaringforyourselfathome?”

“Haveyoufalleninthepastyear?”(Considertryingthe‘getandgo’testforanypatientwhohasexperiencedafall)

3. Writedownthepatient’sresponses.

4. Describeyourimpressionsfromdoingtheexercise.

5. Writedownonethingyouwilldotoassessfunctionandgeriatricsyndromesinyourpracticemovingforward?

Module3:LearnwhatmattersmostThinkbacktoadifficultdecisionyou’vehadtomakethathadimportantimplicationsforyourlife,career,relationshipsandforwhichtherewasnorightanswer.

Q1:Whatarethethingsthathelpedyoumakethedecision?

Q2:Whatkindsoftrade-offsdidyouweighwhenmakingthisdecision?

Q3:Whatfeelingsdidyouexperienceasyouworkedthroughmakingthisdecision?

Q4:Asaclinician,howwouldyourespondtoWilliam’sstatementbelow.Writedownexactwordsyouwoulduse:“Afterhearingthatmykidneysgotworse,Igotscared”

Yourresponse:

Q5:Thinkingaboutthepatientsyoucarefor,writedowntwoadditionalquestionsthatexplorewhat’spatientvaluesandprioritiesinadditiontotheonesyoulearnedinthismodule:

Question1:

Question2:

YourturntopracticeidentifyingtheREMAPskills:WatchthevideobetweenthenephrologyandWilliam.WritedownthespecificwordsthenephrologistusedforeachpartoftheREMAPframework:

Reframethebigpicture(writedownthereframestatement):

Expectandrespondtoemotion(writedowntoempathicstatementstorespondtopatient’semotion):

Mappatientvalues(writedownatleasttwomappingquestionsyouheard):

Alignwiththevalues(writedownastatementyouheardthatsummarizesthepatient’svalues):

Compareyouranswerswith‘checkyourworkandsummaryofREMAP’video.

ReflectionquestionsaboutREMAP:

Q1:WhatsurprisedyouthemostaboutusingREMAPtoelicitpatientvaluesandpriorities?

Q2:WhatisonewaythatREMAPdiffersfromwhatyouusuallydowhenyoudiscusstreatmentdecisionswithpatientsandfamilies?

Q3:What’sonethingyouwilldodifferentlybasedonthismodule?

Module4:MakearecommendationToprepareformakingarecommendationforWilliamandRita,answerthefollowingquestions:

Q1:Whatwasmostimportant(valuesandpriorities)?

William:

Rita:

Q2:Whatthingsdideachonewanttoavoid?

William:

Rita:

Q3:WhattreatmentwouldyourecommendforWilliamandRita–conservativecareortrialofdialysis?

William:

Rita:

Recommendationexercise:It’syourturntopracticemakingarecommendation.Eachexerciseincludestherelevantmedicalandvaluesinformationtoformulatearecommendation.Afteryoucompletebothexerises,compareyouranswerswithanexpertresponse.Exercise1:Medicalhistory:RSisan78yearoldgentlemanwithadvancedsystolicheartfailure(ejectionfraction35%),peripheralvasculardisease,admittedtwiceforheartfailureinthelastyear.HehasdifficultywithADLsandrequiresassistancewithbathing.Heusesawalkertogetaroundandhashad2fallsinthelastyear.Serumalbumin2.8.Usingtouchcalcprognosticcalculator–youestimatethatifhewereondialysis,hehasa50%chanceofdyinginfirst6months.Withdialysis,patient’scurrentfunctionalstatuswouldlikelyworsenwithhighprobabilityofnursinghomeplacement.Aftersharingprognosiswithpatient,belowareresponsestoyour‘mappingvalues’questions:RSresponses:“WhenIthinkaboutthefutureandhowmyhealthhasbeen,it’sbeenhard.WhatIhopeforistogetmystrengthbackandbeabletotakecareofmyselfagain.Ihavealottogetbackto–spendingtimewithmygrandkids,enjoyinggoodhomecookedmealsaroundthetablewithmyfamily.ThisiswhatI’dbedoingallthisfor.Togetbackmylife.

“ThingsIworryabout–wellifthingsdon’tgomywayandmyconditionworsensandgettinghomeisn’tpossible.Iamnotthetypeofpersonwhowantstobeaburdenonmyfamily.Idon’twanttoendupinanursinghomeorinasituationthatIcouldn’tcareformyself.Thatwouldn’tbeliving.

“I’mhopefulthough–hopefulthatIcanbeattheseproblemsandclimboutontop.I’mwillingtobebackinthehospitalifitmeansgettingstrongerandregainingsomeofmylifeback.”

1. Whatwouldbeyourrecommendation?A. ConservativecarewithoutdialysisB. Timelimitedtrialofdialysis

2. Exactlywhatrecommendationwouldyousaytothepatient?Writedownyouexactwords.Example:BasedonX(goals),IwouldrecommendY(plan).

Exercise2:Medicalhistory:RSisan78yearoldgentlemanwithadvancedheartfailure(EF35%),peripheralvasculardisease,admittedtwiceforheartfailureinthelastyear.HehasdifficultywithADLsandrequiresassistancewithbathing.Heusesawalkertogetaroundandhashad2fallsinthelastyear.Serumalbumin2.8.Usingtouchcalcprognosticcalculator–youestimatethatifhewereondialysis,hehasa50%chanceofdyinginfirst6months.Withdialysis,patient’scurrentfunctionalstatuswouldlikelyworsenwithhighprobabilityofnursinghomeplacement.Aftersharingprognosiswithpatient,belowareresponsestoyour‘mappingvalues’questions:RSresponses:“Thesepastmonths,I’vebeeninandoutofthehospital.Ithasn’tmademeanybetter–infactI’mworseoffnowthanever.What’simportanttomeistospendthetimeIhaveleftwithmyfamily.I’velivedagoodlifeandraisedafamilyIamproudof.“I’mtiredofthepainandIwantthelittletimeIhavelefttobewithoutpain.Iwanttodieinmyownhomewithmywifesittingnexttome.“IworrymostaboutmyfamilyandhowtheywilldoonceI’mgone.I’vealwaysbeensomebodywhotookcareofthem.It’shardformetothinkaboutbeingdependentonthem.Iwanttoensurethattheywillbeok.“Iknowdoingmorethingsisn’tgoingtohelpmeandthatmaymeanmytimeisshortIwanttospendmylastdayswithdignity–notgoingbackandforthtoahospital.Iwanttobeoutpfpainandbreathingmylastbreathswithmywifebymyside.”

1. Whatwouldbeyourrecommendation?A. ConservativecarewithoutdialysisB. Timelimitedtrialofdialysis

2. Exactlywhatrecommendationwouldyousaytothepatient?Writedownyouexactwords.Example:BasedonX(goals),IwouldrecommendY(plan).

Exercise1:Belowincludeshowanexpertwouldmakearecommendationforthisexercise.Thiscaseisanexampleofwhylearningthevaluesofthepatientiscriticaltomakingarecommendation.Survivalisuncertainyetwhatthattimelookslikeismorecertain.Dialysismayextendtimewithahighchanceoffunctionalsetbacksincludingdependency.RSresponses:Keyvaluessupportingrecommendationhighlightedinred“WhenIthinkaboutthefutureandhowmyhealthhasbeen,it’sbeenhard.WhatIhopeforistogetmystrengthbackandbeabletotakecareofmyselfagain.Ihavealottogetbackto–spendingtimewithmygrandkids,enjoyinggoodhomecookedmealsaroundthetablewithmyfamily.ThisiswhatI’dbedoingallthisfor.Togetbackmylife.

“ThingsIworryabout–wellifthingsdon’tgomywayandmyconditionworsensandgettinghomeisn’tpossible.Iamnotthetypeofpersonwhowantstobeaburdenonmyfamily.Idon’twanttoendupinanursinghomeorinasituationthatIcouldn’tcareformyself.Thatwouldn’tbeliving.

“I’mhopefulthough–hopefulthatIcanbeattheseproblemsandclimboutontop.I’mwillingtobebackinthehospitalifitmeansgettingstrongerandregainingsomeofmylifeback.”

1. Whatwouldbeyourrecommendation?Timelimitedtrialofdialysis,Althoughthereisasmallchanceofthispatientachievinghisgoalsofgettingstrongerandbackhome,heiswillingtoputupwithshorttermburdenstogetthere.

2. Exactlywhatrecommendationwouldyousaytothepatient?Givenyourgoalsaretogetstrongerandbacktoenjoyinggoodtimeswithyourfamily,Iwouldrecommendatrialofdialysisinhopeofachievingthesegoals.Ifnewsetbackscomeuporthesegoalsbecomelesslikely,wecandiscussstoppingdialysisandshiftingourfocusonyoursymptomsandcomfort.

Exercise2:Belowincludeshowanexpertwouldmakearecommendationforthisexercise.

Youmighthavenoticedthemedicalhistoryisthesameforbothexerciseswithsamesurvivalandfunctionalprognosis:dialysismayextendtimewithahighchanceoffunctionalsetbacksincludingdependency.Notehowvaluesinfluenceadifferentrecommendation.RSresponses:Keyvaluessupportingrecommendationhighlightedinred“Thesepastmonths,I’vebeeninandoutofthehospital.Ithasn’tmademeanybetter–infactI’mworseoffnowthanever.What’simportanttomeistospendthetimeIhaveleftwithmyfamily.I’velivedagoodlifeandraisedafamilyIamproudof.“I’mtiredofthepainandIwantthelittletimeIhavelefttobewithoutpain.Iwanttodieinmyownhomewithmywifesittingnexttome.“IworrymostaboutmyfamilyandhowtheywilldoonceI’mgone.I’vealwaysbeensomebodywhotookcareofthem.It’shardformetothinkaboutbeingdependentonthem.Iwanttoensurethattheywillbeok.“Iknowdoingmorethingsisn’tgoingtohelpmeandthatmaymeanmytimeisshort.Iwanttospendmylastdayswithdignity–notgoingbackandforthtoahospital.Iwanttobeoutpfpainandbreathingmylastbreathswithmywifebymyside.”

1. Whatwouldbeyourrecommendation?Conservativecarewithoutdialysis,Thevaluesexpressedstronglysupportaconservativepath–thepatientiswillingtotradepotentialsurvivalwithdialysisforafocusonsymptomsandendoflife.Conservativecarewillmorelikelyachievehisgoalsofpaincontrol,notsufferingandspendingendoflifeathome.

2. Exactlywhatrecommendationwouldyousaytothepatient?Givenyourgoalsaresymptommanagementandbeingathomeevenifthismeansshortertime,Iwouldrecommendconservativecarewithafocusonachievingthesegoals.Wewillnotpursuedialysisasthistreatmentwillnothelpyouwiththesegoals.

Congratulations,you’vecompletedtheConservativeCareCurriculum!!Reflectionquestion:Writedownonethingyoulearnedfromthiscurriculumthatyouwillcommittopracticeoverthenexttwoweeks?

Thankyouforyourparticipationinthiscurriculum.Pleasecompletethepost-curriculumsurveythatyouwillreceiveshortly!