Palliative and End-of-Life Care in Nephrology

Moving From Observations to Interventions

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

Disclosures

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

In This Article

Conservative Kidney Management

Although overall survival rates for those with ESRD have improved recently, mortality remains relatively high within a few years of dialysis initiation.[23] Patients with ESRD who are older, frail and have multiple comorbidities are more likely to be hospitalized frequently and are at a higher risk of death after the initiation of dialysis compared to other patients with ESRD.[6,9,24–27] Historically, there has been a priority to determine mortality risks once patients have started dialysis in order to better guide prognostic discussions and decisions about long-term therapy.[28] Indeed, several studies have demonstrated that the survival benefit for older patients who receive dialysis is as high as 2 years; however, other studies have shown no difference in survival for older patients who receive dialysis compared to those who receive CKM.[26,29,30–34] For example, Verberne[29] et al. performed a retrospective survival analysis of 311 patients of whom approximately 1/3 chose CKM. There was no survival advantage in using dialysis therapy among patients aged 80 years or greater and reduced survival for patients aged 70 years or greater who had significant comorbidities. Furthermore, in addition to survival, some studies have evaluated patient factors and outcomes relevant to palliative care including functional status, symptoms and quality of life (Table 1).[27,30,33–42] This is quite important as those who are managed with CKM may experience distressing physical and emotional symptoms as well as poor quality of life that increases in intensity as the natural course of the disease progresses.[10,43] However, it is now clear that dialysis therapies may not improve symptom burden or quality of life for older patients with advanced CKD.[27,39,41,42]

In addition, CKM and palliative care have been examined concurrently. One study prospectively assessed the impact of a comprehensive renal palliative care clinic on survival, symptom burden and quality of life on patients with advanced CKD who were managed with CKM.[27] The clinic featured a palliative care specialist and renal/palliative care nurse who focused on illness trajectory discussions, care coordination with the standard renal clinic and serial assessments of symptoms and quality of life. As compared to advanced CKD patients who received standard care, the renal palliative care patients were older (mean age of 82 years vs. 67 years), had higher proportions of clinical dementia, more comorbidities and poorer nutritional status. However, there were no observed differences in survival, symptom burden trajectory or quality of life between CKM patients managed in the renal palliative care clinic and patients who received standard care.[27] This study showed that CKM integrated with palliative was not less efficacious compared to traditional nephrology care that included dialysis therapy and that palliative care can be integrated into treatment paradigms much earlier than is typically done. This mirrors advances in other medical specialties such as oncology, in which the early integration of palliative care into standard care practices has proven to be effective in improving mood, coping and quality of life in addition to survival compared to patients who receive standard care.[44–46] Additional research is needed to establish best practices for comprehensive nephrology care models that include early palliative care to effectively manage patient-centered outcomes and survival.

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