Tackling inequalities in kidney care: 26–28 April, Nottingham

Unleashing the Power of Renal Nutrition in Value-Based Models of Kidney Care Choices: Leveraging Dietitians’ Expertise and Medical Nutrition Therapy to Delay Dialysis Initiation

The aim of this article is to review the current understanding of disparities in healthcare experienced by people living with kidney disease and emerging approaches to address root causes. Health equity for any disease state is an aspirational goal commonly sought out by the medical community, but all too often lacking the understanding and support required to improve the outcomes of people with complex conditions such as chronic kidney disease (CKD). The main themes of the literature covered in this article include a review of the structural drivers of healthcare outcomes, a description of research in the fields of health literacy and patient activation for patients with CKD, and an analysis of the examples of healthcare disparities in CKD patients that include involuntary discharges from dialysis facilities as well as the toll taken from dialysis populations during natural disasters. The National Forum of the ESRD Networks is a coalition of 18 congressionally mandated ESRD network organizations committed to equitable access to home and in-center dialysis modalities and preemptive kidney transplantation. We conclude with the patient-centered story of a patient living with end-stage kidney disease for over 40 years and how her journey has helped shape her view on what she believes should encompass a 'call to action' to provide more equitable healthcare to people living with kidney disease. The overarching implications of this article focus on improving the understanding of present-day healthcare inequality within the community of people living with kidney disease and providing a roadmap of resources and ideas that will help achieve more equitable outcomes. The National Forum of the ESRD Networks is committed to the effective implementation of 'Practicing Health Equity in Kidney Care' and improving access to dialysis modalities including home dialysis as well as kidney transplantation including preemptive transplant options.

A Multinational, Multicenter Study Mapping Models of Kidney Supportive Care Practice

Background:Resource poor nations are froth with various confounding challenges in their social, political, financial, physical and healthcare needs. Care of patients with health problems’, including those with kidney related disorders is associated with many challenges. This study is aimed to highlight the challenges of kidney care in a resource poor nation.Materials and methods:The activity of a private kidney care centre in Nigeria was reviewed from establishment to 6 months of operation. The details were documented and analysed.Result:The commencement of the kidney care centre was delayed as a result of financial and bureaucratic challenges. A total of 64 patients were seen during the period studied, 59.4% were male and the mean age was 48.2±5.5 years. 40.3% of the patients had chronic kidney disease. Twenty patients had haemodialysis however only 2 patients sustained the dialysis for the period studied. Most patients were unable to adhere to medication. The centre still depend on the parent hospital financially.Conclusion:The challenges of kidney care in resource poor nation are numerous and multifactorial.

Knowledge, attitudes and practices (KAP) of kidney care providers regarding climate change, environmental impacts of kidney care and environmentally sustainable kidney care have been assessed in diverse regions worldwide, but little is known about the perspectives of people who receive dialysis therapies. We aimed to assess the KAP of people on dialysis about these subjects. An electronic KAP survey, based on a previous survey of Canadian kidney care providers, was administered to people receiving all available dialysis modalities in a single center in Canada, from December 2024 to May 2025. A total of 69 people responded to the survey, of whom 67% identified as men, and 70% were undergoing in-center hemodialysis (ICHD), 14% home hemodialysis (HHD) and 16% peritoneal dialysis (PD). Most (87%) of the respondents felt informed about climate change to at least an average degree. Nearly half were either extremely or very concerned about climate change (44%) and the waste generated by dialysis treatments (43%), and the levels of concern differed across dialysis modalities. Overall, 51% of respondents never felt guilt or anxiety related to the carbon footprint of dialysis treatment. However, there were significant differences (χ2 test; P < .001) in the occurrence of these feelings depending on the dialysis modality (more frequent in people receiving home modalities, and more in PD than HHD). Most respondents were either very (45%) or slightly (45%) interested in obtaining more information about the themes explored in the survey. This survey showed that most respondents receiving a dialysis therapy felt informed and at least moderately concerned about climate change. Higher levels of concern about climate change and the amount of waste generated by dialysis treatment, as well as more frequent occurrence of guilt/anxiety about the carbon footprint of dialysis were observed in people on home therapies (PD and HHD) compared with ICHD.

Australian healthcare quality and safety accreditation standards recommend health services partner with health care users, to ensure the highest quality of care. Aboriginal Australians with chronic and end stage kidney disease have high health care access needs. To describe the experiences of health care users of a large government kidney healthcare service provider. Within a government renal health service in the Top-End of the Northern Territory, we undertook a qualitative study involving in-depth interviews with 26 adult clients from urban, regional and remote settings who were living with kidney health conditions. Client characteristics included a mean age of 55 years, 55% female and 81% identifying as Aboriginal. The kidney related conditions of client participants included CKD (11, 42.3%), haemodialysis (12, 46.2%), peritoneal dialysis (1, 3.9%), and transplant (2, 7.7%). Key themes emerging from patient interviews related to perceived gaps for clients and carers including: 1) knowledge gaps about the health condition, 2) the impact of relocation in order to access centrally-based renal care, 3) healthcare staff professionalism and qualities and 4) service environments. Overall, the experiences centred on a greater need for client-centred, respectful and culturally based healthcare support. Clients recommended the need for patient-led collective care, including sustaining an Indigenous Patient Reference Group to support ongoing healthcare service decision processes. Participants included in almost equal proportion, clients with CKD (without dialysis) and clients utilising renal replacement therapy, which adds significant weight to the client-identified recommendations for highest quality of kidney care across a wide spectrum of kidney function. Four major themes identified by clients related to their experience with renal care provided by this major regional health care provider: knowledge gaps of their own condition, the lived impacts of relocating to access health care, service environments, and Health Care Provider Quality. An Indigenous Patient Reference Group was one mechanism recommended to support the co-design of preferred care models.

Redefining kidney failure: broadening metrics to realize equity in kidney care.

50 years of the inverse care law

Suicide, a major mental and public health problem, is a leading cause of death and a major challenge to mental health professionals worldwide. The World Health Organisation over many years set an explicit target to reduce suicide rates, however, the reality is that the suicide rates continue to increase. It is now the situation that suicide is one of the main causes of death in men in the industrialized world, along with road traffic accidents (Eurostat 2004), yet the amount of government activity and campaigns targeted at increasing road safety and transport initiatives far outweighs efforts to reduce suicide rates. The paper by Sun et al. (2006) in the first instance serves to place a focus on suicide and then goes on to expose some of the attitudes of nurses and patients underpinning the complex dynamics of a therapeutic relationship in the management of suicidal patients. The relationship between suicide and a previous episode of psychiatric inpatient care has been established (Pirkis & Burgess 1998) and this suggests that initiatives to reduce suicide must be primarily located at the suicidal patient's first point of contact with formal health services. Therefore, it is important to focus research efforts on suicide prevention around the area of suicide assessment/screening of patients at the first point of contact with mental health services and conduct longitudinal studies. The initial focus of such research work would be to screen first time attendee's with psychiatric pathology presenting to the health services and investigate suicidal tendency and ideation within a framework of primary care and prevention. Primary care and prevention must be central for research efforts on suicide if we are to redress the problem of suicide in our society. The study by Sun et al. is primarily focused on secondary care and on patients who have already attempted suicide. Sun et al. provide interesting insights into the inpatient management of suicidal patients and the inclusion of patients voicing their opinions and views is a particular strength of the paper. The patient's perception that medication was the most effective treatment from the whole range of treatments and therapies provided does highlight certain failings in the mental health care system as in recent years the mental health professions have targeted considerable efforts on the development of various therapies such as group therapy; psychotherapy; and recreation therapy. The findings of Sun et al. (2006) would support the requirement for rigorous evaluation of available services using patient perception and, in future, the views of service users must become a central pillar directing professional services and treatment regimes. Sun et al. have been quite forthright and honest in acknowledging the limitations of the study. The inclusion of a sample of single sex nurse respondents provides for an unbalanced account of attitudes, given the role of gender in psychiatric therapeutic relationships and their centrality in the reported findings of the study. A further limitation of the study, which is not highlighted clearly by the authors, is the exclusion of other mental health professionals, for example medical staff, from the data collection phase of the study. The authors do highlight the centrality of team work and collaboration in the management of patients who attempt suicide, furthermore direct comments are attributed to other members of the healthcare team. However, the absence of corroboration or any alternative perspective or responses from other members of the healthcare team makes such comments and discussion rather spurious. A selective quotation from a nurse: It is not only psychiatric nurses that can prevent suicide but all members of the team. Consequently we need team co-operation. This may be seen as unbalanced comment in that it portrays an impression that the lack of team work emanates from other members of the health care team. As proposed by the authors, team work is essential for the successful clinical management of suicidal patients therefore every effort must be made to ensure inclusiveness in research efforts. The authors discuss treatment and therapy in suicide as including five main modes, which are conventional including: medication; electroconvulsive therapy; group therapy; psychotherapy and recreation therapy. There is, however, an over simplistic, minimalist, unsubstantiated approach taken in portraying the role of the psychiatric nurse in very traditional terms and this may not be a reflection of the evolving role of the psychiatric nurse in suicide prevention as it evolves internationally. For example, in the article it is suggested that psychiatrists diagnose the condition and prescribe the medications. The psychiatric nurse administers the medication and ensures that the patients receive it. Psychiatric nursing is and has always been more then this rather basic manual intervention and in modern parlance psychiatric nurses are showing leadership in some areas of suicide prevention. It is well established that the expanded and extended role of the psychiatric nurse includes autonomous and independent therapeutic roles (Cowman et al. 2001). Safety and security in acute psychiatric wards is an essential element in the management of suicide. Violent death by suicide is occurring with increasing frequency and within the hospital setting, environmental dangers must be reduced including the absolute requirement for security precautions to protect suicidal patients from themselves. However, there is a wide variation in safety and security procedures in acute psychiatric wards (Cowman & Walsh 2004). A coherent policy and procedure is an essential requirement in ensuring a safe environment for the suicidal patient. Sun et al. (2006) in the paper are quite correct in drawing our attention to the situation of ensuring a safe environment, which may be restrictive and therefore impairing the autonomy and freedom of patients. However, a further dilemma relates to the tension between on the one hand attempting to provide a nursing therapeutic presence and on the other hand operationalising security procedures (Burrows 1991). In the management of suicidal patients the nursing challenge is to ensure an environment where procedures for safety and security are inextricably fused with a caring perspective. An unusual finding was the strength of judgmental attitudes held by psychiatric nurses towards suicidal patients. The extent to which such attitudes may be culturally context dependent and therefore not generalizable to other jurisdictions requires further discussion. Some very unacceptable and unprofessional nursing practices are reported by patients particularly in relation to the ‘protection room’. Such nursing practices are unethical and from a statutory regulatory nursing perspective in the UK and Ireland would not be consistent with a code of professional conduct and would merit attention through Fitness to Practice procedures. Such findings of malpractice create a dilemma for researchers and are worthy of further discussion in the realm of research ethics. In conclusion, the paper does raise awareness and highlight the centrality of the psychiatric nursing role in the management of the suicidal patient in the acute psychiatric ward. The views of patients are an important inclusion in the study, however, in only presenting the views of nurses an opportunity may have been missed by not examining the views of all members of the professional team in the management of suicidal patients.

How decisions are made and communication is handled are essential to ensuring a good outcome.In the case of Scardoni v Hawryluck,1 Mrs H was an 81-year-old woman with advanced Alzheimer disease, cardiovascular illness, and septic shock whose family and physician could not agree on goals for care, requiring that a legal decision be made regarding the level of care to be provided. Over time and after much discussion, the multidisciplinary team on the intensive care unit (ICU) reached a consensus that intensive care for Mrs H would not improve her condition. So it was decided that after Mrs H was stepped down to a general medical unit, should an infection or respiratory distress develop, she would not be returned to the ICU. The attending ICU physician informed the family that instead of ICU care, “the hospital would offer her palliative care: painkillers and sedatives to keep her comfortable while her afflictions took their course.”2 In this particular case, the patient’s family challenged the health care team’s recommendations and insisted that their mother be readmitted to the ICU so that aggressive life-sustaining treatment would continue.This case, although Canadian, is relevant to ICU settings throughout North America. The purpose of this discussion is not to provide an in-depth ethical analysis, but rather to use the case of Mrs H to characterize one type of health care situation that clinical ethicists could help facilitate. Medical recommendations such as those involved in the care of Mrs H are made to prevent the “revolving door” patient, who according to ICU teams will receive no medical benefit if returned to the ICU. Decisions not to readmit are euphemistically referred to by some ICU staff as the “one-way ticket out of ICU” or “celestial transfer.” Such language shared between colleagues reflects a coping strategy, a “gallows humor,” intended to manage difficult feelings like sadness, anger, grief, sympathy, or moral distress. Cases like that of Mrs H are of particular concern to critical care nursing. Research has indicated that moral distress, a significant contributing factor to burnout, is encountered by ICU nurses when the care they are providing to a patient is regarded as futile.3It is not uncommon for hospital-based clinical ethicists to receive a request for consultation when disputes regarding similar recommendations for care arise between substitute decision makers and the ICU treatment team. These cases can lead to moral distress because of commonly held opinions among team members that futile treatment is being provided. Although staff can provide many life-sustaining treatments to such a patient, ethical questions often arise during the patient’s stay in the ICU. What ought to happen when an ICU team decides that a patient should be transferred to a general medical unit to receive comfort measures only, with no readmission to the ICU? Although teams discuss the practical questions about what can be done, the ethical questions about what ought to be done are sometimes not as clear. The following discussion explores how clinical ethicists can provide valuable assistance with the kinds of ethical challenges these situations customarily present. Particular emphasis will be placed on working within a process-driven, interdisciplinary framework that maintains a communication-oriented approach to ethical decision making.Clinical ethics is a relatively new field, and the role and purpose of clinical ethicists can vary somewhat according to the particular health care setting. For the purpose of this discussion, the authors describe the knowledge, skills, and activities of clinical ethicists through their review of relevant literature as well as their own training and experiences as staff clinical ethicists at 2 acute care settings in Ontario, Canada.Greater legal clarity or legislative measures to specifically address conflicts that arise over withdrawal or withholding of treatment for terminally ill patients are required, according to at least one legal expert. Current Canadian law, according to this same scholar, leaves doctors, patients and their families in a “grey zone” as to who should have ultimate authority on such decisions.4 The daily reality in most North American ICUs is that this gray zone persists—for better or worse. Although hospitals attempt to provide guidelines for addressing conflicts such as the one involving Mrs H, it is the quality of communication and relationship within the interdisciplinary team and between the treating team and the patient’s family that has a marked influence on decision making.5–7 In most cases similar to this one, consensus about level of care is first achieved by the interdisciplinary team, and a subsequent agreement is reached between the treatment team and the patient’s substitute decision maker and family. However, when agreement cannot be reached because of irreconcilable notions pertaining to what constitutes benefit to the patient and what constitutes harm, the results can be uncertain, stressful, and most unsatisfactory for both the health professionals involved and the patient’s family. This combination of an unfortunate turn of events for the patient, sharing of bad news with family members, and the recommendation for care outside of the ICU is a juncture of decision making at which conflict can occur and ethical challenges are most apparent to members of the interdisciplinary team.8,9Much has been written about the difficulties in communication within the ICU and how this affects patient care. Considerable evidence indicates that communication between the ICU team, patients, and patients’ families can be inadequate, leading to conflict and a possible long-term effect on the patient’s family.6,8,10,11 In one study,8 46% of families who had a loved one die in the ICU reported conflict over decisions to withdraw or withhold life-support measures. These family members also reported conflict over the manner in which staff communicated with or behaved toward them. The authors of that study8 cited family members who felt pressured by staff to “hasten their loved one’s death because they placed a burden on valued resources.” The importance of communication between treatment teams and patients and patients’ families cannot be overstated. In addressing the difficulties and deficiencies that have been identified, 2 experts concluded, “communication with caregivers is consistently identified as the most important and least achieved factor in patient/family satisfaction surveys.”12Intensive care is primarily intended to provide maximum benefit to those patients who are likely to recover from their infirmity or trauma.13 When the interdisciplinary team is not clearly communicating ethical considerations as well as the criteria they are using to determine the effectiveness or success of the treatment plan, patients’ families may develop erroneous expectations that life-sustaining interventions will continue to be offered.6 At the same time as a loved one is receiving ICU care with a grim prognosis, families are struggling to come to terms with impending loss. Family functioning or experience in coping with loss,14 unrealistic expectations regarding health outcome, within a societal context of diverse religious or cultural beliefs, can markedly influence families’ decision making about end-of-life care. Such formidable contributing factors further emphasize that effective communication strategies, as well as an appropriate level of sensitivity, ought to be used in ICUs when dealing with patients’ families.11Team communication, in particular communication between disciplines, also has proven problematic in decisions about end-of-life care in the ICU. Critical care nurses have cited difficulties in communication and decision making within interdisciplinary ICU teams. Ferrand et al15 reported that 75% of the nursing staff who participated believed that “collaboration was inadequate during decision making” despite general agreement that such team collaboration is necessary and desired. In another study,16 about one-third of the ICU nurses who participated felt “excluded by physicians from patient care decisions and felt their exclusion to be a detriment to patient care.”In terms of the burdens carried in making decisions about end-of-life care, some evidence suggests that physicians and nurses experience equal burdens. Physicians experience the burdens associated with having to make these decisions, and nurses feel the burden of having to carry out care decisions made by someone else.17 Given the shared burdens that members of the interdisciplinary team face, as well as the reported difficulties in end-of-life care decision making in the ICU, ensuring effective communication is a key feature of high-quality patient care.7 The following discussion is intended to demonstrate how clinical ethicists can be supportive of such strategies for effective communication and decision making.Medical recommendations like those pertaining to the care of patients such as Mrs H are based on best-practice standards of care and are informed by ethical principles like beneficence, nonmaleficence, and autonomy. Continued life-sustaining support in situations where benefit is in question can be regarded as futile, a concept with inherent ethical challenges. As Weijer et al18 point out, the values inherent in medical futility arguments often confuse treatment considered ineffective and treatment that will be effective but will ultimately result in a controversial outcome such as permanent unconsciousness. A team’s decision to not readmit a patient for ICU care can be an attempt to address futility based on controversial outcomes that the team may perceive as causing more harm for the patient than good. Poignantly stated, “if the welfare of the patient is the whole purpose of providing treatment and if that treatment brings needless suffering, then the whole purpose of medicine is defeated.”19 Although the concept of futility in ICU care is a subject worthy of ethical debate, it will not be the focus of this discussion. Rather, the subject of this discussion is the role of clinical ethicists in helping decision makers address ethical considerations such as futility.The results of inadequate communication, misunderstandings, or disagreements arising from divergent views about what is beneficent and the institutional realities surrounding resource allocation can be seen in the moral distress and subsequent moral residue experienced by both the patient’s family members and the health care staff involved. Moral distress occurs when a person can identify the ethically appropriate course of action, but does not feel able to carry this action forward because of barriers that may include lack of resources, legal limits, institutional obstacles, or imbalances in power, for example. Effects of moral distress on an individual can include feelings of anger, frustration, anxiety, or depression.20 Moral residue can be encountered when “deeply held beliefs, values and principles” are set aside at the expense of one’s personal sense of integrity.21 For families of patients, moral residue can manifest in lifelong memories about difficult health care experiences.The experience of moral distress and moral residue are of particular importance to critical care nursing. Some evidence indicates a relationship between an ICU care nurse’s perception of providing futile care, inadequate communication about the care plan within the interdisciplinary team, and the incidence of moral distress, emotional exhaustion, and burnout.3,16,22 Cases like that of Mrs H can present these kinds of challenges to nurses providing care at the bedside. The discussion also highlights how clinical ethicists can assist interdisciplinary teams in addressing ethical challenges that can lead to moral distress.Finally, the ethical climate within our health care settings is shaped by the organizational values inherent in hospital policies, approaches to handling conflict, allocation of human and material resources, the daily-lived experience of staff providing care, and those to whom care is provided.23,24 Economic constraints, resource allocation difficulties, and staffing shortages contribute to the moral climate of health settings, the moral distress of staff, and burnout among health care providers.25,26In cases such as that of Mrs H, the ethical challenges are not just about treatment requests considered inadvisable but also about scarce resources like ventilator-equipped beds in ICU settings. In the minds of some families, the need for an ICU bed is the primary reason that palliative measures are now being recommended. When conflict surrounds decisions about level of care, it is the bedside ICU nurse who fields the questions, concerns, and emotions expressed by patients’ families.It is through such challenging decision making, in which no agreement is reached, that the moral climate is regrettably defined for all persons with a stake in the decision. However oppressive these disagreements feel to both health care professionals and patients’ family members, most often the disagreements, ironically, do not result from a lack of good intentions on either side of the debate. Rather, these circumstances reflect the complex ethical challenges that are inherent in contemporary health care settings. Clinical ethicists can be an important resource to health care teams, patients, and patients’ families in addressing these difficult challenges.Clinical ethicists who provide consultative services may be requested by the ICU team when conflicts such as the one surrounding the planning of Mrs H’s level of care arise. What are the characteristics, skills, and knowledge that make clinical ethicists a useful resource in helping to address conflict over decisions about level of care for stable but critically ill ICU patients?Clinical ethicists come from a diverse background of training: clinical and academic experiences that include but are not limited to medicine, nursing, social work, theology, philosophy, and anthropology. Most clinical ethicists have advanced academic degrees and/or training in clinical ethics. Despite this diversity in background, clinical ethicists engage in common functions: consultative services, research, education and the development of policies pertaining to patient care and organizational ethics.27–29Clinical ethicists are trained to view ethical problems within an interdisciplinary health care environment whose primary commitment should always be to provide the best patient care possible. Patient care and goals for care are best understood through the wishes, beliefs, and values of the patient and the patient’s family. The approach taken by clinical ethicists in providing consultation is to model interdisciplinary collaboration and effective communication with patients and their families, with the objective of enhancing ethical decision making.28–30In effect, clinical ethicists in cases such as the one involving Mrs H act as facilitators of communication and decision making about goals for care, while directing attention to the ethical considerations underlying such decisions. Generally, clinical ethicists can help clarify differences in the way ethical considerations such as sanctity or quality of life are valued on the basis of religious, personal, or cultural values. Some evidence suggests that ethics consultation generally has been useful in preventing or resolving conflicts, and in reducing the incidence of prolonged controversial treatment.31,32 Current trends in the training and education of clinical ethicists have emphasized skills, knowledge, and expertise better suited to provide ethics support in real time as dilemmas and conflict around decisions related to patient care unfold.28What is particularly important about the approach used by most clinical ethicists is the emphasis placed on fair and just processes for decisions of such importance and consequence in an ICU environment.In cases such as the one involving Mrs H, it is not just what decision ought to be made that is of interest to clinical ethicists, but if and why a particular decision is ethically defensible. If so, to whom is it ethically defensible? How ought discussions and conflicts be managed? These questions raise ethical concerns about justice, fairness, and a reasoned approach to decisions of such consequence. Ethical consideration must also be given to the moral climate, how people feel treated, and the concerns and opinions of key persons with a stake in the decision making, with overarching consideration given to trust in the process used to make such important decisions. Therefore clinical ethicists are as concerned with procedural fairness as they are with outcome when assisting with ethically challenging situations in health care settings.Principal aspects of procedural fairness are as follows: that the process for decision making be as transparent as possible to all involved; that concerns of key persons with a stake in the decision making be considered; that the reasons or rationale behind decisions can be understood and defended; that people responsible for decisions be held accountable; and that in the event disagreement occurs, decisions can be reviewed, taking into account the concerns of those who disagree.33 Process-driven approaches to decision making or to resolving conflict used by clinical ethicists are dependent on using frameworks to guide communication. Such frameworks for communication are not just ethically defensible; they have been shown empirically to be part of good practice standards in ICU settings.6,11,34 Lilly et al35(pS398) found that using a standardized framework for communication resulted in health care providers seeing decision making as a “process rather than as an event”—an attribute consistent with principles for ethical decision making.An example of such a framework to guide communication is described by Lautrette et al,34 who identify such attributes as timeliness, opportunities for the patient’s family to speak, use of appropriate and sensitive language, and ensuring that the setting is private and comfortable. In addition to these attributes, clinical ethicists would include discussion of the values in conflict and ethical obligations that underscore decision making.Frameworks for communication appear well supported in the literature anyway, so what makes the involvement of clinical ethicists of added benefit?Despite advances in implementing communication strategies in many settings, improvement in general is needed in managing communication, enhancing understanding, and meeting needs of ICU patients and their families.6,8,10,11 Furthermore, Sherwin36 believes that communication frameworks and hospital policies can be used coercively, to enforce a particular outcome, if those who lead these discussions or who adhere to policies are not reflecting on personal biases, institutional pressures, and ethical considerations.Clinical ethicists act as facilitators, helping to raise important ethical questions, model effective communication, and model ethical decision making by using teachable moments to heighten the awareness and understanding of the ethical considerations in each case. Within most health care settings, necessary and unavoidable imbalances in power are present between various persons who have a stake in the decision making. Clinical ethicists assist in discussing the values that underlie decisions of such importance, making these transparent to and understood by key involved parties. They model the principles of procedural fairness. Inherently challenging decisions about level of care, as in the case of Mrs H, are often met with challenging feelings and opinions, making fairness and ethical reflection more important than less to involved parties.Clinical ethicists advocate for policies and practices that reduce coercive consequences that can arise when members of the ICU treatment team, patients, or patients’ family members feel overruled or dismissed. In conducting an ethics consultation, the clinical ethicist leads discussions with the interdisciplinary team members about ethical considerations that contribute to moral distress, for example, the conflict in the way benefit and harm associated with a particular therapy or level of care are understood. In most instances, the clinical ethicist must ensure that concerns raised by members of the interdisciplinary team and concerns expressed by patients’ family members are shared and considered. This process is handled in an open and transparent manner. In creating an opportunity through the consultative process for the interdisciplinary team to address concerns, related to both areas of conflict and moral distress, clinical ethicists are also capitalizing on valuable teachable moments in which knowledge about ethics and decision making can be enhanced. As Kälvemark Sporrong et al37(p835) concluded, “Ethical competence is a key factor in preventing or reducing moral distress.”We have found that consultation on an individual case often helps treatment teams identify preventative strategies to reduce or avoid conflict and to engage in more timely discussion about ethics the next time a complex care situation arises. Such measures are necessary in creating a moral climate in which discussion about ethics in daily practice can be supported and thus reducing the effects or incidence of moral distress. The potential exists for all members of the interdisciplinary ICU team, including the most responsible physician, to be so engaged in ethical reflection and decision making on challenging cases. Clinical ethicists model skills of effective communication, ethical reflection, and decision making as well as principles of procedural fairness within the consultative process that they facilitate.We are not suggesting that effective communication, procedural fairness, ethical reflection, and decision making are deficient whenever clinical ethicists are not involved in such cases. In reality, complex and ethically challenging cases occur routinely in ICU settings, most often without the involvement of clinical ethicists. What is being proposed is that clinical ethicists should be seen as a valuable resource for addressing challenging cases in the ICU. Better understanding is needed about the role of clinical ethicists and the kinds of assistance they can provide.In most cases, the ICU team and patient’s family agree on recommendations that comfort measures be provided on a medical intermediate care unit or a palliative care unit for a stable but critically ill patient. However, as in the case of Mrs H, these decisions may be met with considerable emotion from the patient’s family and with differences of opinion about benefit and the appropriate level of care. We think that clinical ethicists can be a valuable resource when challenging cases arise. By providing consultation, clinical ethicists can model effective communication, ethical reflection, and decision making, while following principles of procedural fairness, all of which are key elements to upholding ethics in daily practice and are of particular importance when conflict occurs about level of care in the ICU.The following are practical considerations for critical care nurses:

The Diversity and Equity Committee (DEC) of the Asian Pacific Society of Nephrology (APSN) conducted a regional review to characterise disparities in kidney disease burden, healthcare access and nephrology service delivery across the Asia-Pacific (AP) region. A descriptive summary was compiled using national reports, registries, and expert inputs from DEC representatives. Data included kidney disease prevalence, dialysis and transplant modalities, healthcare system characteristics and disparity-related indicators. Comparative insights were drawn across countries using structured tables and narrative synthesis. The AP region exhibits a disproportionate burden of chronic kidney disease (CKD) and kidney failure with marked heterogeneity in disease aetiology, healthcare financing, and infrastructure. High-income countries such as Japan, Korea, Taiwan and Australia demonstrate mature universal insurance systems, comprehensive dialysis networks and national CKD prevention programs. Middle- and lower-income countries-including Indonesia, Myanmar, Mongolia and parts of South and Southeast Asia-face critical challenges such as workforce shortages, limited dialysis and transplant capacity and geographic inequities. Despite these challenges, several countries have introduced exemplary models to enhance equity and sustainability in kidney care: PD-first policies (Hong Kong, Thailand), pay-for-performance CKD programs (Taiwan), Kidney Health Plan 2033 (Korea), HALT-CKD (Singapore), and ACT-KID (Malaysia), indigenous kidney health efforts in Australia and the inclusion of additional insurance points for patient education in Japan. Persistent gaps remain in early detection, transplantation access, rural care and minority equity. Kidney disease care in the Asia-Pacific region reflects both diversity and disparity. Although universal health coverage and national kidney health initiatives have improved access in many countries, substantial inequities persist across geography, income and cultural groups. The collective experiences highlight both common challenges and innovative solutions. Strengthening regional collaboration, policy-driven efforts and sustainable workforce development are essential to achieving equitable kidney health for all.

ABSTRACTBackgroundNo single study contrasts the extent and consequences of inequity of kidney care across the clinical course of kidney disease.MethodsThis population study of Grampian (UK) followed incident presentations of acute kidney injury (AKI) and incident estimated glomerular filtration rate (eGFR) thresholds of <60, <45 and <30 mL/min/1.73 m2 in separate cohorts (2011–2021). The key exposure was area-level deprivation (lowest quintile of the Scottish Index of Multiple Deprivation). Outcomes were care processes (monitoring, prescribing, appointments, unscheduled care), long-term mortality and kidney failure. Modelling involved multivariable logistic regression, negative binomial regression and cause-specific Cox models with and without adjustment of comorbidities.ResultsThere were 41 313, 51 190, 32 171 and 17 781 new presentations of AKI and eGFR thresholds <60, <45 and <30 mL/min/1.73 m2. A total of 6.1–7.8% of the population was from deprived areas and (versus all others) presented on average 5 years younger, with more diabetes and pulmonary and liver disease. Those from deprived areas were more likely to present initially in hospital, less likely to receive community monitoring, less likely to attend appointments and more likely to have an unplanned emergency department or hospital admission episode. Deprivation had the greatest association with long-term kidney failure at the eGFR <60 mL/min/1.73 m2 threshold {adjusted hazard ratio [HR] 1.48 [95% confidence interval (CI) 1.17–1.87]} and this association decreased with advancing disease severity [HR 1.09 (95% CI 0.93–1.28) at eGFR <30 mL/min/1.73 m2), with a similar pattern for mortality. Across all analyses the most detrimental associations of deprivation were an eGFR threshold <60 mL/min/1.73 m2, AKI, males and those <65 years of age.ConclusionsEven in a high-income country with universal healthcare, serious and consistent inequities in kidney care exist. The poorer care and outcomes with area-level deprivation were greater earlier in the disease course.

Communication: Communication best practices (e.g., teaching goals of care conversations/

CKD is a unique character on the stage of noncommunicable diseases in the United States: high prevalence (>20% in adults), significant expense to public payers ($114 billion among Medicare fee-for-service enrollees), and relatively little investment in research ($29 per patient in National

Green nephrology has emerged as a crucial strategy to address the health care sector’s role in the climate crisis, particularly due to the high carbon intensity of dialysis-related services. Aligned with global net-zero commitments, sustainable kidney care can reduce environmental impact while maintaining high standards of patient care. This viewpoint paper proposes a net-zero carbon emissions kidney care center model to address global climate change challenges and advance health care sustainability goals. Based on the United Nations Sustainable Development Goals, we developed a 4D framework: digital transformation, low-carbon health care, circular economy, and preventive medicine. The digital transformation dimension features a precision kidney health system integrating acute and chronic kidney injury digital care models. The low-carbon health care dimension focuses on increasing the rates of kidney transplantation and choosing optimal dialysis modality. The circular economy dimension involves dialysis wastewater recycling, repurposing of medical materials, and integration of renewable energy into facility operations. The preventive medicine dimension incorporates telehealth education, behavioral interventions, and health inequality improvements. This net-zero carbon emissions kidney care model represents an environmental, social, and governance approach to ensuring implementation and continual improvement. It also provides actionable steps for implementing sustainable kidney care and serves as a reference model for net-zero emissions health care systems.