Upstream discussion provided in the ambulatory setting to assist patients with chronic kidney disease considering dialysis.

Objectives: Extensive discussion with renal patients about treatment intensity is not systematically integrated into their care and often occurs during an acute hospitalization. We conducted a "test-of-change" pilot study to assess the utility of providing an upstream discussion in the ambulatory setting as an additional nephrology consult to assist patients with chronic kidney disease considering treatment choices.

Methods: We randomly assigned patients with Stage 4 or Stage 5 chronic kidney disease who had not yet begun renal dialysis to 1 of 2 groups.

Inpatient palliative care consults and the probability of hospital readmission.

Context: Many patients and their families have difficulty making decisions when confronted with complex medical problems. Often their expectations and hopes are beyond what medical science can deliver, and at times their desires seem to conflict with their treatment plans. Additionally, costly tests and treatments with little or no benefit are often explored.