[12] To overcome the barriers above organizations need to facilitate training and this website support for their staff in acquiring the skills necessary for effective ACP. Organizations need to value ACP by allowing adequate time and space for these conversations to take place. To maximize the potential benefit of ACP there need to be organizational systems to store

written Advance Care Plans and make them available to treating clinicians, for example in the Emergency Department. Advance Care Planning may be appropriate at a number of different stages in the trajectory of chronic kidney disease. There is an excess mortality risk conferred by having chronic kidney disease per se,[13] so it is arguable that ACP is relevant to anyone with chronic kidney disease. In particular for those between 65 and 84 years we know that the risk of death from an alternative cause exceeds that of reaching renal replacement therapy until the individual reaches CKD stage 5.[14] CKD

is also associated with a greater rate of cognitive decline in the elderly.[15] If ACP discussions are to take place in elderly or comorbid patients they may therefore need to be initiated earlier in the trajectory of renal disease than the physician would usually begin discussing options for dialysis or conservative care, particularly following an acute illness or if there is clinical suspicion of early cognitive impairment. To fulfil the promise of achieving patient goals for end-of-life find more care, ACP discussions must be documented and stored in such a way that they are accessible to not only the regular family doctor and nephrologist but also health-care staff providing Florfenicol acute care. There needs to be provision for education of health-care professionals about the existence of Advance Care Plans, when to refer to them and in what circumstances AD apply. The treatment preferences of an individual may change over time, particularly with changes in their social circumstances, health

or functional status. For this reason it is important that ACP is regarded as an ongoing process with facility for regular review of any Advance Care Plan, AD or expressed patient preferences to confirm that they still reflect the wishes of the individual.[1, 16] There also needs to be a facility for updating Advance Care Plans stored in the clinical record. Those who initially decline ACP may wish to participate at a later date and it should be clear to the patient that they can reopen the discussion at a later stage and how they might go about doing so. Frank Brennan, Brian Siva and Susan Crail Patients with end-stage kidney disease (ESKD), with or without renal replacement therapy (RRT), are heavily burdened with symptoms that may interact and compound each other. The burden of symptoms experienced by patients on dialysis is rarely mentioned in patient information sheets despite being well documented in research data.