Palliative and End-of-Life Care in Nephrology

Moving From Observations to Interventions

Nwamaka D. Eneanya; Michael K. Paasche-Orlow; Angelo Volandes

Curr Opin Nephrol Hypertens. 2017;26(4):327-334.

Abstract and Introduction

Abstract

Purpose of review In comparison with patients who have other serious illnesses, patients with advanced kidney disease have a higher rate of intensive care utilization at the end of life and receive palliative care less frequently. Consensus and clinical practice guidelines have therefore recommended the incorporation of palliative care earlier in the disease trajectory. This review summarizes recent literature on this aspect of care and will highlight future directions for patient-centered care within palliative nephrology.

Recent findings Patients with advanced kidney disease and their families frequently do not engage effectively with their clinicians to make informed treatment decisions or plan for care at the end of life. Furthermore, racial and ethnic minority patients continue to receive a lower rate of palliative care services compared to other racial groups. Interventions that promote better palliative care communication and education among nephrology clinicians, patients and their families are becoming increasingly more common in nephrology.

Summary Overall, improved understanding of the unique care needs of patients with advanced and end-stage kidney disease provides a solid foundation to improve palliative and end-of-life care delivery among diverse populations in nephrology.

Introduction

The WHO defines palliative care as comprehensive care that improves quality of life for patients and their families who are facing problems associated with life-threatening illnesses.^[1] Specifically, for patients with advanced chronic kidney disease (CKD) and end-stage renal disease (ESRD), palliative care offers a support framework that can address distressing physical and emotional symptoms as well as complex treatment decision-making.^[2–4] Despite ambiguity about the benefit of dialysis therapies for certain patients with ESRD, evidence-based models to aid clinicians, patients and their families in discussing prognosis and engaging in shared decision-making regarding dialysis are lacking.^[3,5] Dialysis may not extend survival for frail or older patients with multiple comorbidities and can negatively impact quality of life and functional status.^[6–9] Conservative kidney management (CKM), which encompasses nondialytic therapy for volume control, anemia, blood pressure, electrolyte/acid-base abnormalities and physical symptoms, may be a reasonable option for patients who may not benefit from dialysis therapies.^[10] An early palliative care approach can address decision-making, several aspects of CKM and care at the end of life including advance care planning, hospice use and bereavement support.^[11] Also, as patients with CKD and ESRD from minority racial-ethnic groups use palliative care resources less often than other racial groups, interventions that consider various differences in knowledge and communication styles may be key in reducing health disparities and improving equal access to effective end-of-life (EOL) care.^[12–14]

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Next Section

Abstract and Introduction
Dialysis Decision-making
Conservative Kidney Management
Advance Care Planning
End-of-life Care
Racial and Ethnic Disparities in Palliative and End-of-life Care
Conclusion
References
Sidebar

Table 1. Conservative kidney management studies that include patient factors and outcomes relevant to palliative care
Author(s)	Year	Conservative kidney management patient characteristics	Renal replacement therapy patient characteristics	Measures/outcomes
Smith et al. [35]	2003	N=63, mean age=71, CrCl < 10, mean number of comorbidities=4.7	N=258, mean age=51, mean number of comorbidities=2.1	Mean modified KPS lower in CKM patients (55 vs. 85)
Joly et al. [30]	2003	N=37, mean age=84.1, ≥ 3 comorbidities=32.4% socially isolated=43%	N=171, mean age=83.2, ≥ 3 comorbidities=20.6%, socially isolated=15%	Mean KPS lower in CKM patients (55 vs. 63)
Murtagh et al. [36]	2007	N=66, mean age=82, stage 5 CKD, Davies comorbidity score ≥ 3=18%	N/A	Mean palliative performance scale percentage=62%. Mean number of symptoms=11.58
De Biase et al.[37]	2008	N=11, mean age=81.5, mean eGFR=11.2, mean number of comorbidities=5.7	N=5, mean age=79.4, mean eGFR=9, mean number of comorbidities=2.6	Mean KPS higher in CKM patients (83.6 vs. 70). No difference in QOL between two groups
Murtagh et al. [38]	2009	N=55, mean age=82, median eGFR=11, Davies comorbidity score ≥3=20%	N/A	Median number of symptoms=6.8
Yong et al. [39]	2009	N=45, mean age=73.1, CrCl < 15	N=134, mean age=58.2, CrCl < 15	No difference in symptom burden and QOL between two groups
Murtagh et al. [40]	2010	N=74, mean age=81, stage 5 CKD, Davies comorbidity score ≥ 3=21.6%	N/A	Median number of symptoms in the last month before death=16.6
Da Silva-Gane et al. [41]	2012	N=30, mean age=77.5, mean eGFR –14.3, high comorbidity=74%	HD patients: N=80, mean age=60.6, mean eGFR=13.3, high comorbidity=35% PD patients: N=44, mean age=48.0, mean eGFR=14.2, high comorbidity=14%	CKM patients had lower KPS and higher anxiety levels compared with PD and HD patients. Life satisfaction decreased below CKM group after dialysis initiation for RRT group
Seow et al. [42]	2013	N=63, median age=60, stage V CKD, CCI ≥ 8	N=38, median age=60, stage V CKD, CCI ≥ 8	CKM group with higher quality of life but lower cognitive function compared with RRT group
Hussain et al.[33]	2013	N=172 patients, stage V CKD	N=269, stage V CKD	76% of CKM group accessed community PC and/or hospice care services vs. 0% of RRT group
Shum et al.[34]	2014	N=42, mean age=75.3, mean modified CCI=4.6	N=157, mean age=73.4, mean modified CCI=4.3	No difference in baseline functional status or mobility between the two groups. CKM group more likely to receive renal PC and less likely to receive bothersome end-of-life interventions compared to RRT groupa
Brown et al.[27]	2015	N=122, mean age=82, stages 4 and 5 CKD patients managed with palliative care, ≥ 3 comorbidities=38%	N=273, mean age=67, stages 4 and 5 CKD patients managed with standard care, ≥ 3 comorbidities=18%	No difference in quality of life or symptom burden between the two groups

CCI, Charlson comorbidity index; CKD, chronic kidney disease; CKM, conservative kidney management; CrCl, creatinine clearance, eGFR, estimated glomerular filtration rate; HD, hemodialysis; KPS, Karnofsky performance scale; PC, palliative care; PD, peritoneal dialysis; RRT, renal replacement therapy.
^aBothersome interventions=receipt of one of the following interventions within 1 month of death – operative or endoscopic intervention, intubation or mechanical ventilation, cardiopulmonary resuscitation and tube feeding for artificial nutrition.