Alvin H. Moss, MD, FACP, FAAHPM, is Professor of Medicine and Director of the Center for Health Ethics and Law at West Virginia University in Morgantown, WV.Dale E. Lupu, MPH, PhD, is Senior Strategic Advisor of the Coalition for Supportive Care of Kidney Patients and Lead Consultant and founder of Daleview Associates in Maryland.Nancy C. Armistead, MPA, is Executive Director of the Mid-Atlantic Renal Coalition in Richmond, VA.Louis Diamond, MBChB, FCP, (SA), FACP, FHIMSS, is Member of the Executive Committee for the Coalition for Supportive Care for Kidney Disease Patients.

This book should be compulsory reading for any nephrologist or trainee nephrologist and would be a useful reference for palliative care physicians and their trainees. And it will be a useful resource for any and all members of the multidisciplinary nephrology team.

• Chapter 1 Overview Section I Why We Need This Book: Unmet Supportive Care Needs of Patients with Kidney Disease Chapter 2 Birth of a Benefit: Brief History of the ESRD Program Nancy Armistead and Jeffrey A. Perlmutter Chapter 3 Unmet Palliative Care Needs of Patients with Kidney Disease and Consequences Kate Schueller and Dale Lupu Chapter 4 Models for Operationalizing Supportive Care in Kidney Care Dale Lupu and Emma Murphy Section II Supportive Care Capacity-Creating the Infrastructure to Provide Kidney Supportive Care Chapter 5 Assessing Patients' Unmet Palliative Care Needs with Tools for Assessment Dr. Chandra Thomas and Amanda Halpin Chapter 6 Primary Palliative Care Education for the Multidisciplinary Nephrology Team J. Pedro Teixeira and Sara A. Combs Chapter 7 Establishing Relationships with Specialty Palliative Care for More Complex Patient Needs Kate Schueller and Joe Rotella Chapter 8 Physician Wellness in Nephrology and Palliative Care Sarah Ramer and Holly Koncicki Section III Patient-Centered Care-Values Guide Care Chapter 9 The Shared Decision-Making Process as the Recommended Standard for Treatment Decisions in Kidney Disease and Requisite Communication Skills to Implement the Process Ernest I. Mandel, Jane O. Schell and Robert A. Cohen Chapter 10 Advance care planning to elicit and respect patient values and preferences Jean L. Holley and J. April Yasunaga Chapter 11 Involving Family and Friends in Palliative Care for Persons with Kidney Disease Elizabeth Anderson and Dave White Chapter 12 The System to Implement Advance Care Planning and Make Proxies, Advance Directives, and Portable Medical Orders Available and Actionable Across Care Settings Valerie Satkoske and Alvin H. Moss Section IV Just Right Care-the Right Care to the Right Person at the Right time Chapter 13 The Role of Estimating and Communicating Prognosis in Kidney Supportive Care Bjorg Thorsteinsdottir and Michael J. Germain Chapter 14 Active Medical Management without Dialysis for Patients with Advanced Chronic Kidney Disease Kelly Li Chapter 15 Systematic Pain Assessment and Management Sara N. Davison Chapter 16 Systematic Non-Pain Symptom Assessment and Management Hana Yu and Jennifer S. Scherer Chapter 17 Systematic Psychosocial and Spiritual Needs Assessment and Management Daniel Cukor and Elissa Kozlov Chapter 18 Geriatric Nephrology Sendromes and Assessment and Management of Cognitive Impairment Edwina A. Brown and Osasuyi Iyasere Chapter 19 Palliative Considerations for the Patient with Acute Kidney Injury in the Intensive Care Unit Tamara Rubenzik and Alvin Moss Section V Throughout the Continuum-Enhanced Support at the End of Life Chapter 20 Coordination of Care and Care Transitions with Primary Care Clinicians, Specialty Palliative Care, and Hospice Areeba Jawed and Joe Rotella Chapter 21 Palliative Dialysis Vanessa Grubbs Chapter 22 Process of Dialysis Withdrawal for Patients Failing to Thrive on Dialysis Daniel Lam and Rebecca J. Schmidt Section VI The Future of Palliative Care Nephrology Chapter 23 Ethical issues in the supportive care of patients with advanced kidney disease Catherine R. Butler and Alvin H. Moss Chapter 24 Transforming practice to support person-centered care for patients with advanced kidney disease Ann M. O'Hare and Nancy Armistead

Alvin H. Moss, MD, FACP, FAAHPM, is Professor of Medicine and Director of the Center for Health Ethics and Law at West Virginia University in Morgantown, WV.Dale E. Lupu, MPH, PhD, is Senior Strategic Advisor of the Coalition for Supportive Care of Kidney Patients and Lead Consultant and founder of Daleview Associates in Maryland.Nancy C. Armistead, MPA, is Executive Director of the Mid-Atlantic Renal Coalition in Richmond, VA.Louis Diamond, MBChB, FCP, (SA), FACP, FHIMSS, is Member of the Executive Committee for the Coalition for Supportive Care for Kidney Disease Patients.

This book should be compulsory reading for any nephrologist or trainee nephrologist and would be a useful reference for palliative care physicians and their trainees. And it will be a useful resource for any and all members of the multidisciplinary nephrology team.

• Chapter 1 Overview Section I Why We Need This Book: Unmet Supportive Care Needs of Patients with Kidney Disease Chapter 2 Birth of a Benefit: Brief History of the ESRD Program Nancy Armistead and Jeffrey A. Perlmutter Chapter 3 Unmet Palliative Care Needs of Patients with Kidney Disease and Consequences Kate Schueller and Dale Lupu Chapter 4 Models for Operationalizing Supportive Care in Kidney Care Dale Lupu and Emma Murphy Section II Supportive Care Capacity-Creating the Infrastructure to Provide Kidney Supportive Care Chapter 5 Assessing Patients' Unmet Palliative Care Needs with Tools for Assessment Dr. Chandra Thomas and Amanda Halpin Chapter 6 Primary Palliative Care Education for the Multidisciplinary Nephrology Team J. Pedro Teixeira and Sara A. Combs Chapter 7 Establishing Relationships with Specialty Palliative Care for More Complex Patient Needs Kate Schueller and Joe Rotella Chapter 8 Physician Wellness in Nephrology and Palliative Care Sarah Ramer and Holly Koncicki Section III Patient-Centered Care-Values Guide Care Chapter 9 The Shared Decision-Making Process as the Recommended Standard for Treatment Decisions in Kidney Disease and Requisite Communication Skills to Implement the Process Ernest I. Mandel, Jane O. Schell and Robert A. Cohen Chapter 10 Advance care planning to elicit and respect patient values and preferences Jean L. Holley and J. April Yasunaga Chapter 11 Involving Family and Friends in Palliative Care for Persons with Kidney Disease Elizabeth Anderson and Dave White Chapter 12 The System to Implement Advance Care Planning and Make Proxies, Advance Directives, and Portable Medical Orders Available and Actionable Across Care Settings Valerie Satkoske and Alvin H. Moss Section IV Just Right Care-the Right Care to the Right Person at the Right time Chapter 13 The Role of Estimating and Communicating Prognosis in Kidney Supportive Care Bjorg Thorsteinsdottir and Michael J. Germain Chapter 14 Active Medical Management without Dialysis for Patients with Advanced Chronic Kidney Disease Kelly Li Chapter 15 Systematic Pain Assessment and Management Sara N. Davison Chapter 16 Systematic Non-Pain Symptom Assessment and Management Hana Yu and Jennifer S. Scherer Chapter 17 Systematic Psychosocial and Spiritual Needs Assessment and Management Daniel Cukor and Elissa Kozlov Chapter 18 Geriatric Nephrology Sendromes and Assessment and Management of Cognitive Impairment Edwina A. Brown and Osasuyi Iyasere Chapter 19 Palliative Considerations for the Patient with Acute Kidney Injury in the Intensive Care Unit Tamara Rubenzik and Alvin Moss Section V Throughout the Continuum-Enhanced Support at the End of Life Chapter 20 Coordination of Care and Care Transitions with Primary Care Clinicians, Specialty Palliative Care, and Hospice Areeba Jawed and Joe Rotella Chapter 21 Palliative Dialysis Vanessa Grubbs Chapter 22 Process of Dialysis Withdrawal for Patients Failing to Thrive on Dialysis Daniel Lam and Rebecca J. Schmidt Section VI The Future of Palliative Care Nephrology Chapter 23 Ethical issues in the supportive care of patients with advanced kidney disease Catherine R. Butler and Alvin H. Moss Chapter 24 Transforming practice to support person-centered care for patients with advanced kidney disease Ann M. O'Hare and Nancy Armistead

Alvin H. Moss, MD, FACP, FAAHPM, is Professor of Medicine and Director of the Center for Health Ethics and Law at West Virginia University in Morgantown, WV.Dale E. Lupu, MPH, PhD, is Senior Strategic Advisor of the Coalition for Supportive Care of Kidney Patients and Lead Consultant and founder of Daleview Associates in Maryland.Nancy C. Armistead, MPA, is Executive Director of the Mid-Atlantic Renal Coalition in Richmond, VA.Louis Diamond, MBChB, FCP, (SA), FACP, FHIMSS, is Member of the Executive Committee for the Coalition for Supportive Care for Kidney Disease Patients.

This book should be compulsory reading for any nephrologist or trainee nephrologist and would be a useful reference for palliative care physicians and their trainees. And it will be a useful resource for any and all members of the multidisciplinary nephrology team.

• Chapter 1 Overview Section I Why We Need This Book: Unmet Supportive Care Needs of Patients with Kidney Disease Chapter 2 Birth of a Benefit: Brief History of the ESRD Program Nancy Armistead and Jeffrey A. Perlmutter Chapter 3 Unmet Palliative Care Needs of Patients with Kidney Disease and Consequences Kate Schueller and Dale Lupu Chapter 4 Models for Operationalizing Supportive Care in Kidney Care Dale Lupu and Emma Murphy Section II Supportive Care Capacity-Creating the Infrastructure to Provide Kidney Supportive Care Chapter 5 Assessing Patients' Unmet Palliative Care Needs with Tools for Assessment Dr. Chandra Thomas and Amanda Halpin Chapter 6 Primary Palliative Care Education for the Multidisciplinary Nephrology Team J. Pedro Teixeira and Sara A. Combs Chapter 7 Establishing Relationships with Specialty Palliative Care for More Complex Patient Needs Kate Schueller and Joe Rotella Chapter 8 Physician Wellness in Nephrology and Palliative Care Sarah Ramer and Holly Koncicki Section III Patient-Centered Care-Values Guide Care Chapter 9 The Shared Decision-Making Process as the Recommended Standard for Treatment Decisions in Kidney Disease and Requisite Communication Skills to Implement the Process Ernest I. Mandel, Jane O. Schell and Robert A. Cohen Chapter 10 Advance care planning to elicit and respect patient values and preferences Jean L. Holley and J. April Yasunaga Chapter 11 Involving Family and Friends in Palliative Care for Persons with Kidney Disease Elizabeth Anderson and Dave White Chapter 12 The System to Implement Advance Care Planning and Make Proxies, Advance Directives, and Portable Medical Orders Available and Actionable Across Care Settings Valerie Satkoske and Alvin H. Moss Section IV Just Right Care-the Right Care to the Right Person at the Right time Chapter 13 The Role of Estimating and Communicating Prognosis in Kidney Supportive Care Bjorg Thorsteinsdottir and Michael J. Germain Chapter 14 Active Medical Management without Dialysis for Patients with Advanced Chronic Kidney Disease Kelly Li Chapter 15 Systematic Pain Assessment and Management Sara N. Davison Chapter 16 Systematic Non-Pain Symptom Assessment and Management Hana Yu and Jennifer S. Scherer Chapter 17 Systematic Psychosocial and Spiritual Needs Assessment and Management Daniel Cukor and Elissa Kozlov Chapter 18 Geriatric Nephrology Sendromes and Assessment and Management of Cognitive Impairment Edwina A. Brown and Osasuyi Iyasere Chapter 19 Palliative Considerations for the Patient with Acute Kidney Injury in the Intensive Care Unit Tamara Rubenzik and Alvin Moss Section V Throughout the Continuum-Enhanced Support at the End of Life Chapter 20 Coordination of Care and Care Transitions with Primary Care Clinicians, Specialty Palliative Care, and Hospice Areeba Jawed and Joe Rotella Chapter 21 Palliative Dialysis Vanessa Grubbs Chapter 22 Process of Dialysis Withdrawal for Patients Failing to Thrive on Dialysis Daniel Lam and Rebecca J. Schmidt Section VI The Future of Palliative Care Nephrology Chapter 23 Ethical issues in the supportive care of patients with advanced kidney disease Catherine R. Butler and Alvin H. Moss Chapter 24 Transforming practice to support person-centered care for patients with advanced kidney disease Ann M. O'Hare and Nancy Armistead