Renal Palliative Care Research Articles

Renal Palliative Care Studies: Coming of Age

Renal Palliative Care Studies: Coming of Age

Palliative care for a mentally incompetent end stage renal failure patient: why is it important?

People with intellectual disabilities are among the most disadvantaged groups in society. Here we report a mentally incompetent end stage renal failure (ESRF) patient with frequent emergency visits who made a significant improvement in symptoms control and reduction in casualty visits after introduction of renal palliative care service. Multidisciplinary approach would be useful in this case.

Reduction of Acute Hospital Admissions and Improvement in Outpatient Attendance by Intensified Renal Palliative Care Clinic Follow-Up: The Hong Kong Experience

BackgroundEnd-stage renal failure patients often fail to attend scheduled renal palliative care clinic (RPCC) follow-up because of acute hospital admissions, causing negative impact on patients' well-being and health care burden. MeasuresThe rates of RPCC attendance, emergency department (ED) attendance, and acute hospital admission per patient from January 2013 to June 2013 were analyzed. InterventionPatients who had more than one ED visit within three months were invited to intensify their RPCC follow-up schedule for symptom assessment, medical advice, psychosocial-spiritual care, and social worker support in the subsequent three months. OutcomesNineteen patients were included. The rate of ED attendance (2.63 vs. 0.63, P < 0.007) and acute hospital admission (1.59 vs. 0.58, P < 0.009) was reduced significantly after intensified follow-up. Clinic attendance rates improved from 56% to 85%. Conclusions/Lessons LearnedOur pilot results suggested that intensifying RPCC follow-up minimized the utilization of acute medical services and improved outpatient attendance at RPCC.

Effect of erythropoiesis-stimulating agents on hemoglobin level, fatigue and hospitalization rate in renal palliative care patients

To investigate the effect of erythropoiesis-stimulating agents (ESAs) on hemoglobin (Hb) level, fatigue and hospitalization rate in renal palliative care (PC) patients. A retrospective cohort study was done between April 2011 and January 2013 in renal palliative care clinic of clustered hospitals in Hong Kong. The study participants included end-stage renal patients (CrCl < 15 ml/h) decided not for dialysis (ESA 39 patients; control 31 patients). From healthcare databases, we retrieved the patient demographics, laboratory results, reasons and time of hospitalizations during the study period. Fatigue was measured by Edmonton Symptom Assessment Scale. Most were elderly patients and about half of patients had underlying diabetes mellitus. Baseline mean Hb levels were similar (7.57 ± 0.97 g/dL for ESA vs 7.77 ± 0.72 g/dL for control). Mean Hb was raised significantly after 3 and 6 months of ESA injections (9.42 and 9.40 g/dL respectively, P < 0.05). Fatigue was reduced significantly at 3 and 6 months after treatment (P = 0.006 and P = 0.017 respectively). All-cause hospitalization was reduced significantly and there was a trend toward reduction in red blood cell transfusion requirement in the ESA group (P = 0.084). This study demonstrated that use of ESAs in renal PC was effective and might help in reducing fatigue and hospitalizations rate.

Opioid Antagonists

Opioid Antagonists

The role of the renal palliative care clinical nurse specialist

It was recognised, as far back as 2002, that patients with advanced kidney disease had palliative care needs that were not being identified or met. Sarah Watson and Winifred Yeboah discuss the importance of renal palliative care clinical nurse specialists in renal units today.

Use of Sertraline for Antihistamine-Refractory Uremic Pruritus in Renal Palliative Care Patients

Uremic pruritus is a common and distressing symptom occurring in 42% to 75% of end-stage renal dialysis (ESRD) patients, even in patients who are adequately dialyzed. We conducted a retrospective review of consecutive patients who presented to the renal palliative care clinic in a single institution with pruritus refractory to antihistamines between April 2011 and September 2012. A total of 99 patients were screened during this period; 20 were eligible for this study. Sertraline was initiated at 25 mg daily orally for the first month, with dosage increment of 25 mg monthly according to clinical response up to a maximum of 200 mg daily as necessary. Patients were followed up every 2 to 4 weeks in the renal palliative care clinic. Study results showed that low-dose sertraline was effective for antihistamine-refractory uremic pruritus in renal palliative care patients. Further placebo-blinded randomized-controlled studies are warranted to clarify our findings.

ADVANCE CARE PLANNING AND END-OF-LIFE CARE IN ADVANCED RENAL FAILURE

People with advanced chronic kidney disease (CKD) have high mortality; substantial physical, emotional and spiritual suffering; and tremendous end-of-life (EOL) care needs. However, their illness trajectories and needs differ from...

Renal Supportive Care and the Primary Care Physician.

General Practitioner are important and should be involved in decision making and Advanced Care Planning for patients with advanced kidney disease Advanced kidney disease has a biphasic nature of life trajectory No treatment does not mean no dialysis for the patient with CKD - CKD care and terminal phase care.

Predictive Modelling Risk Calculators and the Non Dialysis Pathway.

This guideline will review the current prediction models and survival/mortality scores available for decision making in patients with advanced kidney disease who are being considered for a non-dialysis treatment pathway. Risk prediction is gaining increasing attention with emerging literature suggesting improved patient outcomes through individualised risk prediction (1). Predictive models help inform the nephrologist and the renal palliative care specialists in their discussions with patients and families about suitability or otherwise of dialysis. Clinical decision making in the care of end stage kidney disease (ESKD) patients on a non-dialysis treatment pathway is currently governed by several observational trials (3). Despite the paucity of evidence based medicine in this field, it is becoming evident that the survival advantages associated with renal replacement therapy in these often elderly patients with multiple co-morbidities and limited functional status may be negated by loss of quality of life (7) (6), further functional decline (5, 8), increased complications and hospitalisations.

The Renal Palliative Care Program

A 75-year-old man with a 25-year history of type 2 diabetes presents for long-term treatment options. His estimated glomerular filtration rate is 16 mL per minute per 1.73 m(2) of body-surface area. His history is remarkable for ischemic coronary artery disease, congestive heart failure, peripheral artery disease, mild dementia, and colon cancer. He has been admitted to the hospital 4 times in the last 6 months. How should his case be managed?

The ABCs of Renal Palliative Care: Tools for Decision-Making and Symptom Management in Kidney Disease (TH312)

1.Describe role of the palliative care consult in the decision making and symptom management of seriously ill patients with kidney disease.2.Discuss the role of prognostication to guide renal providers and patients in decisions of dialysis initiation, withdrawal, and withholding in seriously ill patients.3.Describe a communication framework for the palliative care consultant to assist renal providers, seriously ill patients, and family members in treatment decisions and goals of care. Kidney disease is common among patients facing serious illness. The kidney disease trajectory is unique to other chronic illnesses and carries a high mortality rate which rivals many cancers. The palliative care provider is tasked with caring for this complex population, presenting unique challenges involving symptom management and treatment decision making. The purpose of this session is to describe the role of the palliative care consultant caring for patients with kidney disease, provide prognostic tools, and provide a framework for engaging in discussions of treatment decisions. The session includes an overview of the kidney disease trajectory and describes common triggers for palliative care consultation. Three common triggers for palliative care involvement along this trajectory will be explored and discussed: (a) discussions of dialysis initiation and withholding in seriously ill patients, (b) symptom management and medication strategies for patients both receiving and not receiving dialysis, and (c) end-of-life issues including dialysis withdrawal and dialysis access failure. We present a framework to elicit patient values and goals specifically addressing kidney disease treatment plans. This framework includes communicating the risks and benefits of dialysis in seriously ill patients and negotiating a care plan which may include withholding dialysis, withdrawing dialysis, or a time-limited treatment trial. By the end of the session, the palliative care provider will have gained new tools and understanding in caring for seriously ill patients with kidney disease. Participants will have an understanding of the unique challenges in treatment decision making; be able to list common symptoms patients experience, including treatment-related issues specific to certain symptoms; and gain an understanding of the prognostic factors and outcomes for different treatment paths. The palliative care provider will have the skill set to communicate care goals and treatment decisions with seriously ill patients with kidney disease.

Geriatric Renal Palliative Care

Elderly patients with advanced chronic kidney disease or who are on dialysis should be able to live as fully and comfortably as possible. Geriatric patients are most interested in outcomes that will optimize mental and physical function and limit suffering and pain. Nephrologists must help them answer the question: "How will my kidney problem affect the way I live now and in the future?" This means management must move beyond glomerular filtration rate-related targets and incorporate geriatric principles that focus on assessment of function, comorbidities, geriatric syndromes, and quality of life issues. Therapeutic decisions should be individualized and directed by patient goals of care, which must be explored and documented. Accomplishing this requires inclusion of the patient's family-support system in the shared decision-making process. There is no substitute for spending time listening to and understanding the patient and family agenda, providing timely medical and prognostic updates; discussing realistic scenarios to balance expectations; and planting the seeds of change as the quantity and quality of medical events, geriatric syndromes, and comorbidities accumulate. Synergy of the interdisciplinary renal team with geriatric and palliative medicine specialists provides the expertise to achieve these goals. This falls into the domain of geriatric renal palliative or supportive care (1) and is the subject of this practical review.

The Ethics of End-of-Life Care for Patients with ESRD

Patients with ESRD have extensive and unique palliative care needs, often for years before death. The vast majority of patients, however, dies in acute care facilities without accessing palliative care services. High mortality rates along with a substantial burden of physical, psychosocial, and spiritual symptoms and an increasing prevalence of decisions to withhold and stop dialysis all highlight the importance of integrating palliative care into the comprehensive management of ESRD patients. The focus of renal care would then extend to controlling symptoms, communicating prognosis, establishing goals of care, and determining end-of-life care preferences. Regretfully, training in palliative care for nephrology trainees is inadequate. This article will provide a conceptual framework for renal palliative care and describe opportunities for enhancing palliative care for ESRD patients, including improved chronic pain management and advance care planning and a new model for delivering high-quality palliative care that includes appropriate consultation with specialist palliative care.

Advance care planning for renal patients

BackgroundThere is increasing evidence of the benefits of advance care planning in patients with advanced kidney disease. End of life care in Advanced kidney disease (2009) A framework for implementation...

Renal supportive care and palliative care: revision and proposal in kidney replacement therapy.

Patients with chronic kidney disease may receive sustained renal supportive care and renal palliative care (RPC) starting with the diagnosis of the disease, throughout the various stages of renal replacement therapy (RRT), the cessation of the RRT, and in the decision of whether to provide conservative treatment or non-initiation of RRT. This article reviews the literature on the development of renal palliative care and proposed RPC models. We describe the progression of disease in organ failure, which is very different from other areas of palliative care (PC). We describe important components of resident nephrology training in PC. We discuss the management of pain and symptom control, as well as communication skills and other psychological and ethical aspects in the renal patient. We conclude that in chronic renal patients, a palliative care approach can provide a positive impact on the quality of life of patients and their families, as well as optimizing the complex treatment of the renal patient.

The challenges of renal replacement therapy and renal palliative care in the elderly

The main aim of this review is to let general practitioners and physicians understand what happens to older patients after referral to the renal service. Usually, most patients will be managed completely by the renal team, either because the patient requires dialysis or because conservative but specialised care is appropriate. The recent increase in dialysis rate can mostly be accounted for by older patients for whom such demanding treatment was previously thought to be contraindicated. The decision to dialyse the elderly still remains difficult, with recent data suggesting that if there are significant comorbidities the survival advantage of dialysis in patients over 75 years of age is unlikely to be more than four months. Towards the end of life, conservative treatment is not simply a decision not to dialyse, but comprises active disease management, including treatment of anaemia and other supportive care, which may become increasingly complex, e.g. pain relief with fentanyl and alfentanyl. Older patients who decide to accept dialysis treatment contend with all the usual end of life issues of older people. They have an additional option, denied to the rest of us, of dialysis withdrawal; this effectively allows them to die at a time of their choosing.

Integrating Palliative Care for Patients with Advanced Chronic Kidney Disease: Recent Advances, Remaining Challenges

Patients with ESRD have extensive and unique end-of-life care considerations and needs. Despite substantial advancements in renal palliative care over the past decade, much research is still required. Identifying CKD patients whose illness trajectory has shifted and would likely benefit from a palliative approach to care should be a priority of all nephrology programs. Further research on symptom management, the effectiveness of ACP, the life expectancy of conservatively managed and incident dialysis patients, anticipated changes in functional status and HRQL with the initiation of dialysis (especially among the frail elderly), and the best way to deliver renal palliative care is required to maximize the integration and effectiveness of renal palliative care services.

Palliative care in advanced kidney disease: a nurse-led joint renal and specialist palliative care clinic

The National Service Framework for Renal Services Part 2 identifies quality requirements for end-of-life care for individuals with kidney failure, recognizing the potential to forge closer relationships between renal and specialist palliative care providers. This article describes a pilot project set up by two Clinical Nurse Specialists, one working in hospice specialist palliative care and the other in renal palliative care within an acute trust. The purpose of the pilot was to work in collaboration to run a streamlined nurse-led clinic that would meet the palliative care needs of chronic kidney disease (CKD) Stage 5 patients and their carers. To achieve this the clinic would have to provide optimal symptom management, empower patients to make their own choices, and support them with advance care planning underpinned by the End of Life Care Strategy. The partnership also aimed to promote service improvement and practice development using transference of knowledge, skills, and expertise. Initial informal feedback, including a very small patient survey, suggests that the clinic was well received by patients, carers, and other health professionals. The clinic is ongoing and deserves more formal evaluation to encourage future service development.

Renal palliative care in Australia: Time to engage

Renal palliative care in Australia: Time to engage