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. 

In This Article

Advance Care Planning

Patients with advanced CKD and ESRD are at an increased risk of death compared to other patients with life-limiting illnesses.[23,47] Furthermore, patients with ESRD on dialysis have high rates of hospitalizations, intensive care unit admissions and intensive procedures, but low rates of hospice utilization.[48] Early involvement of palliative care can ensure that timely discussions occur to ensure patients have the opportunity to consider their options for care at the end of life and communicate their preferences to their clinicians and families.[19,49] Discussions about EOL care preferences and written advance directives, including living wills and healthcare proxy forms, allow patients to plan ahead for care in the event of serious or critical illness. Importantly, effective advance care planning results in greater patient satisfaction with care, greater hospice utilization and lower rates of in-hospital death.[50–53] Few patients with CKD and ESRD complete advance directives and even fewer have EOL discussions with their clinicians.[54,55] O'Hare et al.[56] performed a recent qualitative analysis of clinician perspectives (from various specialties including nephrology, primary care, cardiology and so on) who cared for patients with advanced kidney disease. The results showed that the complexity of disease, fragmentation of care and lack of a collaborative approach were some of the perceived barriers to effective implementation of advance care planning. These findings highlight the need for interdisciplinary clinical teams wherein team members have clearly defined roles to streamline the advance care planning process. However, while this study was focused mainly on interactions between clinicians, others have highlighted the impact of surrogate decision-makers on advance care planning.[57–60] Patients' families and other loved ones are frequently encountered with difficult treatment decisions that can cause significant emotional burden.[61] Song et al.[62] piloted a structured communication intervention delivered by nurses trained in assessing and eliciting care goals among maintenance dialysis patients and their surrogates. This programme was effective in increasing patient and surrogate congruence on goals of care as well as surrogate decision-making confidence. Interventions that incorporate the perspectives of multispecialty clinicians, patients and their families as well as feature a structured interdisciplinary approach should become standard of care to ensure engagement in advance care planning and subsequent goal-oriented care at the end of life in nephrology.[3,17]