DECISION SUPPORT SYSTEM FOR RENAL REPLACEMENT THERAPY AND COMPREHENSIVE PATIENT SUPPORT INCLUDING END-OF-LIFE CARE AT FUSSA HOSPITAL.

 For a long time, the decision-making process for renal replacement therapy in Japan has been dominated by healthcare providers, with insufficient support provided to patients. In Japan, medical expenses related to dialysis treatment are essentially covered at no cost to the patient through the social security system. This has long been a lifeline for patients with end-stage renal disease in Japan and has also fostered the perception that a life with renal replacement therapy is inherently beneficial for any patient. However, with Japan's rapidly aging population, the average age of dialysis patients has exceeded 70 years. Since 2022, the number of dialysis patients has begun to decline for the first time. Against this backdrop, Japanese kidney disease care is shifting toward strengthening decision support for renal replacement therapy while also emphasizing palliative care for renal failure.

Fussa Hospital Renal Replacement Therapy Decision Support System implements shared decision-making support in three stages, tailored to the level of kidney function. Each session allocates 30 minutes to over an hour for dialogue involving the patient, family, physician, and nurse. Furthermore, during subsequent outpatient visits, nurses provide decision support at every appointment, ensuring continuous intervention (Figure 1). This presentation reviews cases intervened upon through the support system and examines the significance of patients choosing their own life paths. Furthermore, regarding the nursing approach for conservative kidney management. which remains underdeveloped in Japan, we examine five cases where consent was obtained for presentation from individuals who completed their lives without selecting renal replacement therapy at our hospital.

Practice report and Case study. 

From 2018 to 2023, 248 patients received decision support through our support system. Nurses regularly assessed patients' weight, blood pressure, edema, appetite, and living conditions during outpatient visits while listening to their thoughts regarding renal replacement therapy. When information was insufficient for decision-making, additional information was provided, and referrals to specialists were made as appropriate.

For patients who did not choose renal replacement therapy, symptom management for uremic symptoms was provided. Additionally, confirmation of the final living arrangements and psychological care were offered to patients and their families. Five patients (2 males, 3 females) died, with an average age at death of 80.4 years. The average nursing intervention period was 20.8 months, with an average of 23 nursing interventions. Interventions by the Clinical Nurse Specialist (CNS) as Advanced Practice Nurse, including home visits and phone calls to check on the patient's condition, averaged 14.8 times.

The Decision Support System for Renal Replacement Therapy at Fussa Hospital aims for patient-centered decision-making, moving away from the previous model heavily reliant on healthcare providers. Our renal replacement therapy decision support, interventions spanning years lead not only to patient-centered care but also to advance care planning (ACP) involving families. Furthermore, through community collaboration, it is believed this approach can facilitate the individualized end-of-life care desired by patients choosing conservative renal therapy and their families.