Development of an Integrated Advance Care Planning Model for Enhancing Palliative Care in Community-Based Patients with Chronic Kidney Disease
Keywords:
Advance care planning, Chronic kidney disease, Community-based care, Palliative careAbstract
Introduction: End-stage chronic kidney disease (CKD) patients face complex physical, psychosocial, and spiritual needs. However, community-based health systems often lack a systematic integration of Advance Care Planning (ACP) and palliative care, resulting in end-of-life care that may not align with patients’ values and preferences.
Objectives: To present knowledge regarding the development of an integrated advance care planning model to promote palliative care among patients with chronic kidney disease at the community level.
Key contents: The development of the integrated advance care planning model for promoting palliative care among patients with chronic kidney disease in community settings consisted of four major phases: situation analysis, model design, implementation, and model refinement. The model comprised six core components: (1) leadership, (2) empowerment, (3) service flow, (4) information systems, (5) community engagement, and (6) tools. The outcomes of implementing the model demonstrated positive impacts on patients, families, healthcare providers and communities, as well as the overall healthcare service system.
Conclusion: The integrated advance care planning model to promote palliative care among patients with chronic kidney disease at the community level provides a patient-centered and system-oriented approach that emphasizes community engagement. The model contributes to improving quality of life, reducing family burden, and enhancing the efficiency of healthcare service delivery.
Implications: This model should be promoted for implementation across primary healthcare settings nationwide. Furthermore, long-term outcome evaluations are recommended to generate policy-relevant evidence for the sustainable development of community-based palliative care systems for patients with chronic kidney disease.
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