Palliative care in end-stage kidney disease




ROBERT G FASSETT^1,2,3,*, 

 

IAIN K ROBERTSON⁴, 

 

ROSE MACE⁶, 

 

LOREN YOUL⁵, 

 

SARAH CHALLENOR⁶, 

 

ROSALIND BULL⁵

1. ^{1Renal Research, Royal Brisbane and Women's Hospital}
2. ^{2School of Medicine, The University of Queensland, Brisbane}
3. ^{3School of Human Movement Studies, The University of Queensland, St. Lucia, Queensland, Schools of}
4. ^{4Human Life Sciences}
5. ^{5Nursing and Midwifery, University of Tasmania}
6. ^{6Renal Unit, Launceston General Hospital, Launceston, Tasmania, Australia}

Nephrology, 16: 4–12. doi: 10.1111/j.1440-1797.2010.01409.x  (http://onlinelibrary.wiley.com/doi/10.1111/j.1440-1797.2010.01409.x/full)

Abstract

Patients with end-stage kidney disease have significantly increased morbidity and mortality. While greater attention has been focused on advanced care planning, end-of-life decisions, conservative therapy and withdrawal from dialysis these must be supported by adequate palliative care incorporating symptom control. With the increase in the elderly, with their inherent comorbidities, accepted onto dialysis, patients, their nephrologists, families and multidisciplinary teams, are often faced with end-of-life decisions and the provision of palliative care. While dialysis may offer a better quality and quantity of life compared with conservative management, this may not always be the case; hence the patient is entitled to be well-informed of all options and potential outcomes before embarking on such therapy. They should be assured of adequate symptom control and palliative care whichever option is selected. No randomized controlled trials have been conducted in this area and only a small number of observational studies provide guidance; thus predicting which patients will have poor outcomes is problematic. Those undertaking dialysis may benefit from being fully aware of their choices between active and conservative treatment should their functional status seriously deteriorate and this should be shared with caregivers. This clarifies treatment pathways and reduces the ambiguity surrounding decision making. If conservative therapy or withdrawal from dialysis is chosen, each should be supported by palliative care. The objective of this review is to summarize published studies and evidence-based guidelines, core curricula, position statements, standards and tools in palliative care in end-stage kidney disease.

The role of palliative care in end-stage kidney disease (ESKD) is well developed in the UK, USA, Italy and Canada.^1–9 Palliative care in ESKD is important in the contexts of conservative therapy (choosing a non-dialysis pathway), withdrawal of therapy and in symptom control. Advanced care directives and end-of-life decisions overarch these pathways. There is a recognized need for education regarding provision of palliative care in dialysis patients.¹⁰ However, there is no clear pathway to palliative care,¹¹ considerable variation in the provision of palliative care services for ESKD patients¹² and little evidence upon which to develop standards of renal palliative care in ESKD.¹³ There has been an increase in the elderly accepted onto dialysis in Australia. In 2004, 244 (445 per million population) new patients were accepted on dialysis in the 75–79 year age group. This increased to 277 (504 per million) in 2008. In the 80–84 year age group 103 (267 per million) started dialysis in 2004, which increased to 187 (442 per million) in 2008 and in the >85 year group 32 (107 per million) started dialysis in 2004, which increased to 58 (159 per million) in 2008.¹⁴ Despite this, the Caring for Australasians with Renal Impairment (CARI) Guidelines do not address palliative care.¹⁵ In addition, many elderly assessed for dialysis either do not progress¹⁶ or die before they would have required dialysis therapy.¹⁷

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