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

End-of-life Care

Patients with ESRD on dialysis experience a high rate of intense care at the end of life and this phenomenon has increased over time.[48,63,64] Furthermore, aggressive care at the end of life is strongly associated with worse quality of life near death.[52,65] Although the discontinuation of dialysis and the use of hospice before death have expanded for patients with ESRD, this population continues to use palliative care services less often compared to other patients with chronic diseases.[23,66] Wachterman et al.[66] recently explored quality of EOL care among patients with serious illnesses. As compared to patients with cancer and dementia, ESRD patients used less palliative care consultations, do-not-resuscitate orders and inpatient hospice in the last 90 days of life. Bereaved family members of patients with ESRD also reported less satisfaction with EOL care, less pain control for their loved ones and less favorable interactions with healthcare professionals. However, after controlling for palliative care consultations, do-not-resuscitate orders and place of death, there were no longer disease-mediated differences in terms of satisfaction with EOL care as well as interactions with healthcare professionals about concordant care desired. Despite the increasing repertoire of evidence describing the benefit of palliative care consultations on EOL care quality for patients and their families, studies of integrated palliative care interventions among patients with advanced CKD and ESRD are lacking.[67] This may in part be because of known differences in illness trajectories that occur between patients with cancer, frailty and cognitive diseases compared to those with solid-organ dysfunction.[68,69] Nonetheless, the need for early palliative care education and consultations becomes especially salient for patients with advanced and end-stage kidney disease who are at high risk of death in order to achieve better EOL quality metrics (Fig. 1).[70–73]

Figure 1.

The impact of palliative care consultations on quality metrics at the end-of-life. Adapted from results of referenced studies [70–73].