부산대학교 도서관

Context: Multidisciplinary care (MDC) is considered best practice in the treatment planning and care for patients with chronic disease. MDC is an integrated team approach to health care in which medical and allied health professionals consider all relevant treatment options and collaboratively develop an individual treatment and care plan for each patient. Mortality is higher in patients with chronic kidney disease (CKD) than in the general population. Co-morbidities, treatment burden, increasing age and frailty all affect quality of life. In 2020, we implemented a renal supportive care multidisciplinary meeting (RSC MDM) to identify patients with complex care needs; to improve patient care and coordination; and to transition patients better from dialysis to end-of-life care. Objectives: To report on the implementation and outcomes of monthly RSC MDM reviews within a nephrology service. Key messages: Introduction of a new service-wide RSC MDM requires planning and open communication between all staff. The RSC MDM also serves as an important way to support each other within the service as we care for our complex patients. Monthly meetings have resulted in a forum to discuss complex nephrology patients including: • Symptom management and quality of life • Psychosocial issues and support • Assistance with advance care planning • Increasing frailty with changing functional capacity • Recurrent hospital presentations Conclusion: The introduction of the RSC MDM has been an extremely positive experience. It requires ongoing collaboration and dissemination of information to all staff working across the nephrology service and has improved communication and teamwork in helping to improve overall patient outcomes.