Palliative care for end-stage renal disease patients

An increasingly older End-Stage Renal Disease (ESRD) population requires nephrologists to focus upon issues relating to palliative care. The Renal Physicians Association (RPA), for example, sponsored an evidence-based guideline relating to withholding and withdrawing from dialysis, and the United Kingdom Expert Consensus Group published guidelines for symptom management in adults dying with Chronic Kidney Disease (CKD). Kidney Disease: Improving Global Outcomes (KDIGO) sponsored a workgroup on the topic of palliative or supportive care in CKD outlining the need for additional study and the initiation of palliative treatments. Since nearly 20% of dialysis patients stop dialysis before death and increasingly, older patients are choosing not to begin dialysis in part due to poor outcomes and decreasing functional status with dialysis, it is likely that all nephrologists will be involved in end-of-life care of ESRD and CKD patients. As a group, however, physicians are poorly trained in palliative care and often feel uncomfortable with the responsibility of dying patients. In one survey of American and Canadian physicians, for example, only approximately 40% of 360 nephrologists stated that they were very well prepared to make end-of-life decisions. Despite the identification of the importance of palliative care in ESRD care, nephrology fellows remain uncomfortable and poorly trained in these aspects of clinical care. The primary aim of this talk is to highlight the importance of this critical point and make nephrologists more aware and more familiar with dealing with such a problematic and essential topic. Palliative care is comprehensive, interdisciplinary care focusing on pain and symptom management, advance-care planning and communication, psychosocial and spiritual support, and, in end-stage renal disease (ESRD), the ethical issues in dialysis decision making. End-of-life care is one aspect of palliative care and incorporates all of the previously mentioned components as well as hospice and bereavement care. ESRD patients and their families are appropriate candidates for palliative care because of their high symptom burden, shortened survival, and significant comorbidity. The usual pattern of illness trajectory in ESRD is a progressive decline punctuated by episodes of acute deterioration prompted by sentinel events like limb amputation or myocardial infarction. Such events provide opportunities for advance-care planning and communication between providers and patients and families. Although communication is an integral component of palliative care, little is understood about effective provider-patient communication, especially in estimating and discussing prognosis. Palliative care has much to offer toward improving the quality of dialysis patients' lives as well as planning for and improving the quality of their deaths.

Author(s): Mahmoud Montassers

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