Renal palliative care

Global Assessment of Palliative Care Need: Serious Health-Related Suffering Measurement Methodology

CONTEXT

Inequities and gaps in palliative care access are a serious impediment to health systems especially in low- and middle-income countries and the accurate measurement of need across health conditions is a critical step to understanding and addressing the issue. Serious Health-related Suffering (SHS) is a novel methodology to measure the palliative care need and was originally developed by The Lancet Commission on Global Access to Palliative Care and Pain Relief. In 2015, the first iteration - SHS 1.0 - was estimated at over 61 million people worldwide experiencing at least 6 billion days of SHS annually as a result of life-limiting and life-threatening conditions.

OBJECTIVES

In this paper, an updated methodology - SHS 2.0 - is presented building on the work of the Lancet Commission and detailing calculations, data requirements, limitations, and assumptions.

METHODS AND RESULTS

The updates to the original methodology focus on measuring the number of people who die with (decedents) or live with (non-decedents) SHS in a given year to assess the number of people in need of palliative care across health conditions and populations. Detail on the methodology for measuring the number of days of SHS that was pioneered by the Lancet Commission, is also shared, as this second measure is essential for determining the health system responses that are necessary to address palliative care need and must be a priority for future methodological work on SHS.

CONCLUSIONS

The methodology encompasses opportunities for applying SHS to future policy making assessment of future research priorities particularly in light of the dearth of data from low- and middle-income countries, and sharing of directions for future work to develop SHS 3.0.

Facilitators and Barriers to Receiving Palliative Care in People with Kidney Disease: Predictive Factors from an International Nursing Perspective

BACKGROUND

Palliative care (PC) focuses on relieving pain and difficult symptoms rather than treating disease or delaying its progress. Palliative care views death as a natural process and allows patients to live the last phase of their existence in the best possible way, encouraging them to express their opinions and wishes for a good death. Interventions are advocated to control symptoms and distress and promote wellbeing and social functioning. A multidisciplinary approach to support patients receiving palliative care is encouraged.

OBJECTIVE

The aims of this study were to investigate the facilitators and barriers to PC in people with kidney disease from a nursing perspective and to explore predictive factors associated with nurse-perceived facilitators and barriers to PC in people with kidney disease.

DESIGN

This study is a survey that adopted a questionnaire created in 2021 with Delphi methology, which included 73 statements divided into 37 facilitators and 36 barriers to PC in patients with kidney disease, to be scored using a Likert scale.

PARTICIPANTS AND MEASUREMENTS

Participants were obtained through the membership database of the European Dialysis and Transplant Nurses Association/European Renal Care Association (EDTNA/ERCA) of 2020. Inclusion criteria included being registered as a nurse, an EDTNA/ERCA member and understanding of the English language. The questionnaire was sent via email.

RESULTS

Three profiles of respondents were found: the first group was characterized by the highest agreement percentages of facilitators and with an average value of 53.7% in barriers; the second was characterized by a lower endorsement of facilitators and similar agreement to the first group for barriers; the third group had a high probability (>80%) of items endorsing both barriers and facilitators. Predictive variables were significantly associated with "Years in nephrology" and "macro geographic area".

CONCLUSIONS

This study demonstrates variation in PC practice across Europe. Some professionals identified fewer barriers to PC and appeared more confident when dealing with difficult situations in a patient's care pathway, while others identified more barriers as obstacles to the implementation of adequate treatment. The number of years of nephrology experience and the geographical area of origin predicted how nurses would respond. This study was not registered.

Referral Criteria to Specialist Palliative Care for People with Advanced Chronic Kidney Disease: A Systematic Review

CONTEXT

People with advanced chronic kidney disease (CKD) have significant morbidity, yet for many, access to palliative care occurs late, if at all.

OBJECTIVES

This study sought to examine criteria for referral to specialist palliative care for adults with advanced CKD with a view to improving use of these essential services.

METHODS

Systematic review of studies detailing referral criteria to palliative care in advanced CKD conducted and reported according to the Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) guideline and registered (PROSPERO: CRD42021230751).

DATA SOURCES

Electronic databases (Ovid, MEDLINE, Ovid Embase, and PubMed) were used to identify potential studies, which were subjected to double review, data extraction, thematic coding, and descriptive analyses.

RESULTS

Searches yielded 650 unique titles ultimately resulting in 56 studies addressing referral criteria to specialist palliative care in advanced CKD. Of 10 categories of referral criteria, most commonly discussed were: Critical times of treatment decision making (n = 23, 41%); physical or emotional symptoms (n = 22, 39%); limited prognosis (n = 18, 32%); patient age and comorbidities (n = 18, 32%); category of CKD/ biochemical criteria (n = 13, 23%); functional decline (n = 13, 23); psychosocial needs (n = 9, 16%); future care planning (n = 9, 16%); anticipated decline in illness course (n = 8, 14%); and hospital use (n = 8, 14%).

CONCLUSION

Clinicians consider referral to specialist palliative care for a wide range of reasons, with many related to care needs. As palliative care continues to integrate with nephrology, our findings represent a key step towards developing consensus criteria to standardize referral for patients with chronic kidney diseases.

Palliative Care in Patients with End-Stage Renal Disease: A Meta Synthesis

End-stage renal disease is the last stage of chronic kidney disease and is associated with a decreased quality of life and life expectancy. This study aimed to explore palliative care with end-stage renal disease. Qualitative meta-synthesis was used as the study design. The search was performed for qualitative studies published until June 2021 and uses reciprocal translation and synthesis of in vivo and imported concepts. Five themes were included: Struggling to face the disease, experiencing deterioration, overcoming the challenges of dialysis, leading to a positive outlook, and preparing for the end of life. In facing chronic disease with life-limiting potential, patients experienced some negative feelings and deterioration in their quality of life. Adaptation to the disease then leads patients to a better outlook through increased spirituality and social status. Furthermore, by accepting the present condition, they started to prepare for the future. Increasing awareness of mortality leads them to discuss advance care (ACP) planning with healthcare professionals and families.

Cause of death for people with end-stage kidney disease withdrawing from treatment in Australia and New Zealand

BACKGROUND

Withdrawal from renal replacement therapy is common in patients with end-stage kidney disease (ESKD), but end-of-life service planning is challenging without population-specific data. We aimed to describe mortality after treatment withdrawal in Australian and New Zealand ESKD patients and evaluate death-certified causes of death.

METHODS

We performed a retrospective cohort study on incident patients with ESKD in Australia, 1980-2013, and New Zealand, 1988-2012, from the Australian and New Zealand Dialysis and Transplant registry. We estimated mortality rates (by age, sex, calendar year and country) and summarized withdrawal-related deaths within 12 months of treatment modality change. Certified causes of death were ascertained from data linkage with the Australian National Death Index and New Zealand Mortality Collection database.

RESULTS

Of 60 823 patients with ESKD, there were 8111 treatment withdrawal deaths and 26 207 other deaths over 381 874 person-years. Withdrawal-related mortality rates were higher in females and older age groups. Rates increased between 1995 and 2013, from 1142 (95% confidence interval 1064-1226) to 2706/100 000 person-years (95% confidence interval 2498-2932), with the greatest increase in 1995-2006. A third of withdrawal deaths occurred within 12 months of treatment modality change. The national death registers reported kidney failure as the underlying cause of death in 20% of withdrawal cases, with other causes including diabetes (21%) and hypertensive disease (7%). Kidney disease was not mentioned for 18% of withdrawal patients.

CONCLUSIONS

Treatment withdrawal represents 24% of ESKD deaths and has more than doubled in rate since 1988. Population data may supplement, but not replace, clinical data for end-of-life kidney-related service planning.

Opioid Safety and Concomitant Benzodiazepine Use in End-Stage Renal Disease Patients

Background

Opioid use is common in end-stage renal disease (ESRD) patients. However, safety of individual opioids and concomitant benzodiazepine use has not been studied.

Objective

To study the epidemiology of opioid and concomitant benzodiazepine use in ESRD population. To study the clinical safety profile of individual opioids in patients on hemodialysis.

Design

Retrospective analysis of the U.S. Renal Data System. A comprehensive review of the current literature was performed to update currently used opioid safety classification.

Participants

ESRD patients ≥18 years on hemodialysis who were enrolled in Medicare A and B and Part D between 2006 and 2012, excluding those with malignancy.

Main Measures

Hospital admission with diagnosis of prescription opioid overdose within 30, 60, and 90 days of prescription; death due to opioid overdose.

Results

Annually, the percentage of patients prescribed any opioid was 52.2%. Overall trend has been increasing except for a small dip in 2011, despite which the admissions due to opioid overdose have been rising. 30% of those who got a prescription for opioids also got a benzodiazepine prescription. 56.5% of these patients received both prescriptions within a week of each other. Benzodiazepine use increased the odds of being on opioids by 3.27 (CI 3.21–3.32) and increased the odds of hospitalization by 50%. Opioids considered safe such as fentanyl and methadone were associated with 3 and 6 folds higher odds of hospitalization within 30 days of prescription. Hydrocodone had the lowest odds ratio (1.9, CI 1.8–2.0).

Conclusions

Concurrent benzodiazepine use is common and associated with higher risk of hospitalization due to opioid overdose. Possible opioid-associated hospital admission rate is 4-5 times bigger in ESRD population than general population. Current safety classification of opioids in these patients is misleading, and even drugs considered safe based on pharmacokinetic data are associated with moderate to very high risk of hospitalization. We propose a risk-stratified classification of opioids and suggest starting to use them in all ESRD patients.

Appointment utilization as a trigger for palliative care introduction: A retrospective cohort study

BACKGROUND

Chronic kidney disease palliative care guidelines would benefit from more diverse and objectively defined health status measures.

AIM

The aim is to identify high-risk patients from administrative data and facilitate timely and uniform palliative care involvement.

DESIGN

It is a retrospective cohort study.

SETTING/PARTICIPANTS

In total, 45,368 Veterans, with chronic kidney disease Stage 3, 4, or 5, were monitored for up to 6 years and categorized into three groups, based on whether they died, started dialysis, or avoided both outcomes.

RESULTS

Patient's appointment utilization was a significant predictor for both outcomes. It separated individuals into low, medium, and high appointment utilizers. Among the low appointment utilizers, the risk of death did not change significantly, while the risk of dialysis increased. Medium appointment utilizers had a stable risk of death and a decreasing risk of dialysis. Significant appointment utilization (above 31 visits during the baseline year) helped high-risk patients avoid both outcomes of interest-death and dialysis.

CONCLUSION

Our model could justify the creation of a novel palliative care introduction trigger, as patients with medium demand for care may benefit from additional palliative care evaluation. The trigger could facilitate the uniformization of conservative treatment preparations. It could prompt messages to a managing physician when a patient crosses the threshold between low and medium appointment utilization. It may also aid in system-level policy development. Furthermore, our results highlight the benefit of significant appointment utilization among high-risk patients.

Palliative care for acute kidney injury patients in the intensive care unit

Patients with acute kidney injury (AKI) in the intensive care unit (ICU) are often suitable for palliative care due to the high symptom burden. The role of palliative medicine in this patient population is not well defined and there is a lack of established guidelines to address this issue. Because of this, patients in the ICU with AKI deprived of the most comprehensive or appropriate care. The reasons for this are multifactorial including lack of palliative care training among nephrologists. However, palliative care in these patients can help alleviate symptoms, improve quality of life, and decrease suffering. Palliative care physicians can determine the appropriateness and model of palliative care. In addition to shared decision-making, advance directives should be established with patients early on, with specific instructions regarding dialysis, and those advance directives should be respected.

Characteristics and Outcomes of In-Hospital Palliative Care Consultation among Patients with Renal Disease Versus Other Serious Illnesses

BACKGROUND AND OBJECTIVES

Despite significant morbidity and mortality associated with ESRD, these patients receive palliative care services much less often than patients with other serious illnesses, perhaps because they are perceived as having less need for such services. We compared characteristics and outcomes of hospitalized patients in the United States who had a palliative care consultation for renal disease versus other serious illnesses.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

In this observational study, we used data collected by the Palliative Care Quality Network, a national palliative care quality improvement collaborative. The 23-item Palliative Care Quality Network core dataset includes demographics, processes of care, and clinical outcomes of all hospitalized patients who received a palliative care consultation between December of 2012 and March of 2016.

RESULTS

The cohort included 33,183 patients, of whom 1057 (3.2%) had renal disease as the primary reason for palliative care consultation. Mean age was 71.9 (SD=16.8) or 72.8 (SD=15.2) years old for those with renal disease or other illnesses, respectively. At the time of consultation, patients with renal disease or other illnesses had similarly low mean Palliative Performance Scale scores (36.0% versus 34.9%, respectively; P=0.08) and reported similar moderate to severe anxiety (14.9% versus 15.3%, respectively; P=0.90) and nausea (5.9% versus 5.9%, respectively; P>0.99). Symptoms improved similarly after consultation regardless of diagnosis (P≥0.50), except anxiety, which improved more often among those with renal disease (92.0% versus 66.0%, respectively; P=0.002). Although change in code status was similar among patients with renal disease versus other illnesses, from over 60% full code initially to 30% full code after palliative care consultation, fewer patients with renal disease were referred to hospice than those with other illnesses (30.7% versus 37.6%, respectively; P<0.001).

CONCLUSIONS

Hospitalized patients with renal disease referred for palliative care consultation had similar palliative care needs, improved symptom management, and clarification of goals of care as those with other serious illnesses.

End-of-life care decisions for haemodialysis patients - 'We only tend to have that discussion with them when they start deteriorating'

BACKGROUND

Haemodialysis patients receive very little involvement in their end-of-life care decisions. Issues relating to death and dying are commonly avoided until late in their illness. This study aimed to explore the experiences and perceptions of doctors and nurses in nephrology for involving haemodialysis patients in end-of-life care decisions.

METHODS

A semi-structured qualitative interview study with 15 doctors and five nurses and thematic analysis of their accounts was conducted. The setting was a large teaching hospital in Wales, UK.

RESULTS

Prognosis is not routinely discussed with patients, in part due to a difficulty in estimation and the belief that patients do not want or need this information. Advance care planning is rarely carried out, and end-of-life care discussions are seldom initiated prior to patient deterioration. There is variability in end-of-life practices amongst nephrologists; some patients are felt to be withdrawn from dialysis too late. Furthermore, the possibility and implications of withdrawal are not commonly discussed with well patients. Critical barriers hindering better end-of-life care involvement for these patients are outlined.

CONCLUSIONS

The study provides insights into the complexity of end-of-life conversations and the barriers to achieving better end-of-life communication practices. The results identify opportunities for improving the lives and deaths of haemodialysis patients.

Quality of Life of Patients with Advanced Chronic Kidney Disease Receiving Conservative Care without Dialysis

With the evidence that dialysis may not necessarily be beneficial for older adults with advanced chronic kidney disease (CKD), there is a growing interest in promoting conservative care without dialysis as a viable treatment option for these individuals. This review summarizes the current empirical evidence of symptom experiences and quality of life of patients receiving conservative care. Data suggest that conservative care may yield symptom experiences and quality of life that are compatible with those of patients on dialysis. However, these data are exclusively from studies conducted outside of the United States in which there were often no comparison groups or study designs that could provide high quality evidence. There is an urgent need for further research and developing a conservative care model suitable for CKD populations in the U.S.

Conservative Care of the Elderly CKD Patient: A Practical Guide

Palliative care is a branch of medicine dedicated to the relief of symptoms experienced during the course of illness. Renal palliative medicine or kidney supportive care is an evolving branch of nephrology, which incorporates the principles of palliative care into the care of CKD and ESRD (dialysis, transplant, and conservatively managed) patients. Conservative (non-dialytic) management is a legitimate option for frail, elderly CKD patients in whom dialysis may not lead to an improvement in quality or duration of life. Patients with advanced CKD have a high symptom burden that often worsens before death. Palliative or supportive care by visiting nurses, palliative care programs, or knowledgeable CKD programs should be routine for conservatively managed CKD patients. Decision-making about dialysis or conservative management requires patients and families be given information on prognosis, quality of life on dialysis, and options for supportive care. Advance care planning is the process by which these issues can be explored. In addition to advance care planning, because patients with ESRD have a high symptom burden, this needs to be addressed. Patients with ESRD have a high symptom burden, which needs to be addressed in any treatment plan. Common symptoms include pain, fatigue, insomnia, pruritus, anorexia, and nausea. Symptoms appear to increase as the patient nears death, and this must be anticipated. Recommendations for management are discussed in the article. Hospice care should be offered to all patients who are expected to die within the next 6 months, and supportive care should be provided to all CKD patients managed conservatively or with dialysis.

Spirituality in Renal Supportive Care: A Thematic Review

Chronic kidney disease is marked by a reduced life expectancy and a high symptom burden. For those who reach end-stage renal disease, the prognosis is poor, and this combined with the growing prevalence of the disease necessitates supportive and palliative care programmes that will address people's psychosocial, cultural and spiritual needs. While there is variation between countries, research reveals that many renal specialist nurses and doctors are reluctant to address spirituality, initiate end-of-life conversations or implement conservative treatment plans early. Yet, other studies indicate that the provision of palliative care services, which includes the spiritual dimension, can reduce symptom burden, assist patients in making advanced directives/plans and improve health-related quality of life. This review brings together the current literature related to renal supportive care and spirituality under the following sections and themes. The introduction and background sections situate spirituality in both healthcare generally and chronic kidney disease. Gaps in the provision of chronic kidney disease spiritual care are then considered, followed by a discussion of the palliative care model related to chronic kidney disease and spirituality. Chronic kidney disease spiritual needs and care approaches are discussed with reference to advanced care planning, hope, grief and relationships. A particular focus on quality of life is developed, with spirituality named as a key dimension. Finally, further challenges, such as culture, training and limitations, are explicated.

Content Validation of a Novel Screening Tool to Identify Emergency Department Patients With Significant Palliative Care Needs

BACKGROUND

The emergency department (ED) is increasingly used by patients with life-limiting illness. These patients are frequently admitted to the hospital, where they suffer from poorly controlled symptoms and are often subjected to marginally effective therapies. Palliative care (PC) has emerged as the specialty that cares for patients with advanced illness. PC has been shown to reduce symptoms, improve quality of life, and decrease resource utilization. Unfortunately, most patients who could benefit from PC are never identified. At present, there exists no validated screening tool to identify significant unmet PC needs among ED patients with life-limiting illness.

OBJECTIVES

The objective was to develop a simple, content-valid screening tool for use by ED providers to identify ED patients with significant PC needs. A positive screen would result in an inpatient PC consultation.

METHODS

An initial screening tool was developed based on a critical review of the literature. Content validity was determined by a two-round modified Delphi technique using a panel of PC experts. The expert panel reviewed the items of the tool for accuracy and necessity using a Likert scale and provided narrative feedback. Expert's responses were aggregated and analyzed to revise the tool until consensus was achieved. Greater than 80% agreement, as well as meeting Lawshe's critical values, was required to achieve consensus.

RESULTS

Fifteen experts completed two rounds of surveys to reach consensus on the content validity of the tool. Three screening items were accepted with minimal revisions. The remaining items were revised, condensed, or eliminated. The final tool contains 13 items divided into three steps: 1) presence of a life-limiting illness, 2) unmet PC needs, and 3) hospital admission. The majority of panelists (86%) endorsed adoption of the final screening tool.

CONCLUSIONS

Use of a modified Delphi technique resulted in the creation of a content-validated screening tool for identification of ED patients with significant unmet PC needs. Further validation testing of the instrument is warranted.

Advance care planning and end-of-life decision making in dialysis: a randomized controlled trial targeting patients and their surrogates

BACKGROUND

Few trials have examined long-term outcomes of advance care planning (ACP) interventions. We examined the efficacy of an ACP intervention on preparation for end-of-life decision making for dialysis patients and surrogates and for surrogates' bereavement outcomes.

STUDY DESIGN

A randomized trial compared an ACP intervention (Sharing Patient's Illness Representations to Increase Trust [SPIRIT]) to usual care alone, with blinded outcome assessments.

SETTING & PARTICIPANTS

420 participants (210 dyads of prevalent dialysis patients and their surrogates) from 20 dialysis centers.

INTERVENTION

Every dyad received usual care. Those randomly assigned to SPIRIT had an in-depth ACP discussion at the center and a follow-up session at home 2 weeks later.

OUTCOMES & MEASUREMENTS

PRIMARY OUTCOMES

preparation for end-of-life decision making, assessed for 12 months, included dyad congruence on goals of care at end of life, patient decisional conflict, surrogate decision-making confidence, and a composite of congruence and surrogate decision-making confidence.

SECONDARY OUTCOMES

bereavement outcomes, assessed for 6 months, included anxiety, depression, and posttraumatic distress symptoms completed by surrogates after patient death.

RESULTS

PRIMARY OUTCOMES

adjusting for time and baseline values, dyad congruence (OR, 1.89; 95% CI, 1.1-3.3), surrogate decision-making confidence (β=0.13; 95% CI, 0.01-0.24), and the composite (OR, 1.82; 95% CI, 1.0-3.2) were better in SPIRIT than controls, but patient decisional conflict did not differ between groups (β=-0.01; 95% CI, -0.12 to 0.10).

SECONDARY OUTCOMES

45 patients died during the study. Surrogates in SPIRIT had less anxiety (β=-1.13; 95% CI, -2.23 to -0.03), depression (β=-2.54; 95% CI, -4.34 to -0.74), and posttraumatic distress (β=-5.75; 95% CI, -10.9 to -0.64) than controls.

LIMITATIONS

Study was conducted in a single US region.

CONCLUSIONS

SPIRIT was associated with improvements in dyad preparation for end-of-life decision making and surrogate bereavement outcomes.

Advance care planning: a qualitative study of dialysis patients and families

BACKGROUND AND OBJECTIVES

More than 90,000 patients with ESRD die annually in the United States, yet advance care planning (ACP) is underutilized. Understanding patients' and families' diverse needs can strengthen systematic efforts to improve ACP.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

In-depth interviews were conducted with a purposive sample of patients and family/friends from dialysis units at two study sites. Applying grounded theory, interviews were audiotaped, professionally transcribed, and analyzed in an iterative process. Emergent themes were identified, discussed, and organized into major themes and subthemes.

RESULTS

Thirteen patients and nine family/friends participated in interviews. The mean patient age was 63 years (SD 14) and five patients were women. Participants identified as black (n=1), Hispanic (n=4), Native American (n=4), Pacific Islander (n=1), white (n=11), and mixed (n=1). Three major themes with associated subthemes were identified. The first theme, "Prior experiences with ACP," revealed that these discussions rarely occur, yet most patients desire them. A potential role for the primary care physician was broached. The second theme, "Factors that may affect perspectives on ACP," included a desire for more of a connection with the nephrologist, positive and negative experiences with the dialysis team, disenfranchisement, life experiences, personality traits, patient-family/friend relationships, and power differentials. The third theme, "Recommendations for discussing ACP," included thoughts on who should lead discussions, where and when discussions should take place, what should be discussed and how.

CONCLUSIONS

Many participants desired better communication with their nephrologist and/or their dialysis team. A number expressed feelings of disenfranchisement that could negatively impact ACP discussions through diminished trust. Life experiences, personality traits, and relationships with family and friends may affect patient perspectives regarding ACP. This study's findings may inform clinical practice and will be useful in designing prospective intervention studies to improve patient and family experiences at the end of life.

Management of ethical issues related to care of seriously ill dialysis patients in free-standing facilities

CONTEXT

There are few data on the frequency and current management of clinical ethical issues related to care of seriously ill dialysis patients in free-standing dialysis facilities.

OBJECTIVES

To examine the extent of clinical ethical challenges experienced by care providers in free-standing facilities and their perceptions about how those issues are managed.

METHODS

A total of 183 care providers recruited from 15 facilities in North Carolina completed a survey regarding the occurrence and management of ethical issues in the past year. Care plan meetings were observed at four of the facilities for three consecutive months. Also, current policies and procedures at each of the facilities were reviewed.

RESULTS

The two most frequently experienced challenges involved dialyzing frail patients with multiple comorbidities and caring for disruptive/difficult patients. The most common ways of managing ethical issues were discussions in care plan meetings (n = 47) or discussions with the clinic manager (n = 47). Although policies were in place to guide management of some of the challenges, respondents were often not aware of those policies. Also, although participants reported that ethical issues related to dialyzing undocumented immigrants were fairly common, no facility had a policy for managing this challenge. Participants suggested that all staff obtain training in clinical ethics and communication skills, facilities develop ethics teams, and there be clear policies to guide management of ethical challenges.

CONCLUSION

The scope of ethical challenges was extensive, how these challenges were managed varied widely, and there were limited resources for assistance. Multifaceted efforts, encompassing endeavors at the individual, facility, organization, and national levels, are needed to support staff in improving the management of ethical challenges in dialysis facilities.

Improving symptom management in hemodialysis patients: identifying barriers and future directions

BACKGROUND

Hemodialysis (HD) patients experience significant symptom burden that is often undertreated.

OBJECTIVE

This study identified (1) barriers to symptom management in the HD population, (2) potential targets for improving symptom burden, (3) provider attitudes toward palliative care for HD patients, and (4) perceptions of how transplant eligibility impacts care.

DESIGN

Semistructured, one-on-one interviews were conducted, audiotaped, and transcribed. Data were analyzed qualitatively by two investigators to identify discrete themes.

SETTING/SUBJECTS

Health care providers (HCPs) and caregivers were recruited (June to October 2012) from three outpatient HD units in New York City.

MEASUREMENTS

Open-ended questions were used with follow-up probes.

RESULTS

Interviews were completed with 34 HCPs (8 physicians, 2 nurse practitioners, 4 social workers, 13 registered nurses, 7 patient care technicians) and 20 caregivers (14 family members, 5 home health aides, 1 friend). Barriers to symptom control were identified in three areas: (1) provider unawareness of symptoms, (2) provider's uncertainty as to whose responsibility it is to treat symptoms, and (3) inherent difficulty in symptom management. Ideas for ameliorating symptoms included enhancing systems for patient/caregiver education, improving systems for HCP communication with other disciplines, and encouraging alternative methods of dialysis when appropriate. HCPs also expressed discomfort with the term "palliative care."

CONCLUSIONS

Renal HCPs are often unaware of the magnitude of symptom burden in their HD patients. This study found that there is lack of ownership for assessing and treating these symptoms. Providers also feel certain symptoms are "untreatable." Research is needed to develop effective treatment strategies for HD populations.

A palliative approach to dialysis care: a patient-centered transition to the end of life

As the importance of providing patient-centered palliative care for patients with advanced illnesses gains attention, standard dialysis delivery may be inconsistent with the goals of care for many patients with ESRD. Many dialysis patients with life expectancy of <1 year may desire a palliative approach to dialysis care, which focuses on aligning patient treatment with patients' informed preferences. This commentary elucidates what comprises a palliative approach to dialysis care and describes its potential and appropriate use. It also reviews the barriers to integrating such an approach into the current clinical paradigm of care and existing infrastructure and outlines system-level changes needed to accommodate such an approach.

Chronic kidney disease and support provided by home care services: a systematic review

BACKGROUND

Chronic diseases, such as chronic kidney disease (CKD), are growing in incidence and prevalence, in part due to an aging population. Support provided through home care services may be useful in attaining a more efficient and higher quality care for CKD patients.

METHODS

A systematic review was performed to identify studies examining home care interventions among adult CKD patients incorporating all outcomes. Studies examining home care services as an alternative to acute, post-acute or hospice care and those for long-term maintenance in patients' homes were included. Studies with only a home training intervention and those without an applied research component were excluded.

RESULTS

Seventeen studies (10 cohort, 4 non-comparative, 2 cross-sectional, 1 randomized) examined the support provided by home care services in 15,058 CKD patients. Fourteen studies included peritoneal dialysis (PD), two incorporated hemodialysis (HD) and one included both PD and HD patients in their treatment groups. Sixteen studies focused on the dialysis phase of care in their study samples and one study included information from both the dialysis and pre-dialysis phases of care. Study settings included nine single hospital/dialysis centers and three regional/metropolitan areas and five were at the national level. Studies primarily focused on nurse assisted home care patients and mostly examined PD related clinical outcomes. In PD studies with comparators, peritonitis risks and technique survival rates were similar across home care assisted patients and comparators. The risk of mortality, however, was higher for home care assisted PD patients. While most studies adjusted for age and comorbidities, information about multidimensional prognostic indices that take into account physical, psychological, cognitive, functional and social factors among CKD patients was not easily available.

CONCLUSIONS

Most studies focused on nurse assisted home care patients on dialysis. The majority were single site studies incorporating small patient populations. There are gaps in the literature regarding the utility of providing home care to CKD patients and the impact this has on healthcare resources.

Patients with cirrhosis and denied liver transplants rarely receive adequate palliative care or appropriate management

BACKGROUND & AIMS

Patients with cirrhosis who are receiving palliative care and are not eligible for liver transplantation (LT) are often hospitalized multiple times, with lack of expectations or understanding of death and dying. We evaluated how frequently these patients received appropriate and palliative care.

METHODS

We performed a retrospective study of 102 consecutive adult patients (67% men; mean age, 55 years) who were removed from the list for or declined LT from January 2005 through December 2010 at the University of Alberta, Canada. Patients' medical records were reviewed to determine their access to palliative care and relief of symptoms, the appropriateness of the goals for their care, and their requirements for acute care services.

RESULTS

The patients' median Model for End-stage Liver Disease score was 20, and median time from denial of LT to death was 52 days (range, 10-332 days). The most common reasons that patients were removed from the transplant wait list were noncompliance or substance abuse (26%) and severe illness or organ dysfunction (25%). After patients were removed from the list, 17% received renal replacement therapy, and 48% were subsequently admitted to the intensive care unit. Patients spent a median of 14 days (range, 6-33 days) in the hospital after they were removed from the transplant wait list. On the basis of the Edmonton Symptom Assessment System, 65% of patients had evidence of pain, 58% had evidence of nausea, 10% had depression, 36% had anxiety, 48% had dyspnea, and 49% had symptoms of anorexia. Twenty-eight percent of all the patients had documentation of do not resuscitate status on their charts, and only 11% were referred for palliative care.

CONCLUSIONS

Patients with cirrhosis who have been removed from the wait list for LT are infrequently referred for palliative care (∼ 10% of cases), although a high percentage have pain or nausea. Goals of care and do not resuscitate status are rarely discussed. Improved planning of goals of care and access to palliative services are required for these patients.

Withdrawal from Dialysis and Palliative Care for Severely Ill Dialysis Patients in terms of Patient-Centered Medicine

We treated a dementia patient with end stage chronic kidney disease (CKD). The patient also had severe chronic heart disease and suffered from untreatable respiratory distress during the clinical course of his illness. We therefore initiated peritoneal dialysis therapy (PD) as renal replacement therapy, although we had difficulties continuing stable PD for many reasons, including a burden on caregivers and complications associated with PD therapy itself. Under these circumstances we considered that palliative care prior to intensive care may have been an optional treatment. This was a distressing decision regarding end-of-life care for this patient. We were unable to confirm the patient's preference for end-of-life care due to his dementia. Following sufficiently informed consent the patient's family accepted withdrawal from dialysis (WD). We simultaneously initiated nonabandonment and continuation of careful follow-up including palliative care. We concluded that the end-of-life care we provided would contribute to a peaceful and dignified death of the patient. Although intensive care based on assessment of disease is important, there is a limitation to care, and therefore we consider that WD and palliative care are acceptable options for care of our patients in the terminal phase of their lives.

Pathways to palliative care for patients with chronic kidney disease

BACKGROUND

Despite the terminal nature of chronic kidney disease (CKD), end-of-life care planning is often inconsistent and pathways to palliative care are unclear. Health professionals' perceptions of palliative care and the prevailing context may influence their end-of-life decision making.

OBJECTIVES

To identify predictors of conservative treatment decisions and their associations with referral to palliative care, and to determine the perceptions that health professionals have about the role of palliative care in management of CKD.

METHODS

A retrospective audit of deceased patients' charts, spanning three years, and a survey of renal healthcare professionals, documenting CKD palliative care practices, knowledge and attitudes was carried out. Records of all patients with CKD dying between 1 January 2006 and 31 December 2008 in Australian regional renal service were audited. Renal staff from the service were surveyed. Logistic regression for binomial outcomes and ordinal logistic regression when more than two outcome levels were involved; and thematic analysis using a continual cross comparative approach was undertaken.

RESULTS

Loss of function, particularly from stroke, and severe pain are interpreted as representing levels of suffering which would justify the need to withdraw from renal replacement therapy. Family and/or patient indecision complicates and disrupts end-of-life care planning and can establish a cycle of ambiguity. Whilst renal healthcare professionals support early discussion of end-of-life care at predialysis education, congruity with the patient and family when making the final decision is of great importance.

CONCLUSION

Healthcare professionals' beliefs, values and knowledge of palliative care influence their end-of-life care decisions. The influence of patient, family and clinicians involves negotiation and equivocation. Health professionals support the early discussion of end-of-life care in CKD at predialysis education to enable clearer decision making.

Dialysis in the frail elderly--a current ethical problem, an impending ethical crisis

The current practice of hemodialysis for the frail elderly frequently ignores core bioethical principles. Lack of transparency and shared decision making coupled with financial incentives to treat have resulted in problems of overtreatment near the end of life. Imminent changes in reimbursement for hemodialysis will reverse the financial incentives to favor not treating high-risk patients. In this article, we describe what is empirically known about the approach to hemodialysis today, and how it violates four core ethical principles. We then discuss how the new financial system turns physician and organizational incentives upside down in ways that may exacerbate the ethical dilemmas, but in the opposite direction.

Disconnect between emergency contacts and surrogate decision-makers in the absence of advance directives

BACKGROUND

The role played by emergency contacts can be extensive particularly for chronically seriously ill patients. If the patient's condition suddenly deteriorates, the emergency contact may be asked to make decisions that should instead fall to a designated surrogate decision-maker.

AIMS

To describe a process used to help chronically seriously ill patients identify a surrogate during study enrollment and to describe whether these surrogates were the same as the documented emergency contacts.

DESIGN

A descriptive cross-sectional study using eligibility assessment and baseline data from an efficacy trial. The parent trial tests the effects of an end-of-life communication intervention on patient and surrogate decision-maker outcomes, and thus, it was important to identify the surrogate. The study recruiter used a short battery of investigator-developed questions to help patients identify a surrogate.

SETTING/PARTICIPANTS

Patients were 94 self-identified African Americans or Caucasians recruited from 18 outpatient dialysis centers, receiving dialysis for ≥6 months, with Charlson Comorbidity Index of ≥6 or 5 and hospitalized in the last 6 months.

RESULTS

When first approached, only three patients had a designated and documented surrogate. The remaining 91 selected a surrogate during the surrogate identification process. Of the 94 surrogates who were named, only 60 (63.8%) were also listed in the medical record as the emergency contact.

CONCLUSIONS

In roughly one-third of instances, the selected surrogate was not the same person listed in official medical records as the emergency contact, which may pose potential problems in medical decision-making in the absence of advance directives.

Ageism vs. the technical imperative, applying the GRADE framework to the evidence on hemodialysis in very elderly patients

Purpose

Treatment intensity for elderly patients with end-stage renal disease has escalated beyond population growth. Ageism seems to have given way to a powerful imperative to treat patients irrespective of age, prognosis, or functional status. Hemodialysis (HD) is a prime example of this trend. Recent articles have questioned this practice. This paper aims to identify existing pre-synthesized evidence on HD in the very elderly and frame it from the perspective of a clinician who needs to involve their patient in a treatment decision.

Patients and methods

A comprehensive search of several databases from January 2002 to August 2012 was conducted for systematic reviews of clinical and economic outcomes of HD in the elderly. We also contacted experts to identify additional references. We applied the rigorous framework of decisional factors of the Grading of Recommendation, Assessment, Development and Evaluation (GRADE) to evaluate the quality of evidence and strength of recommendations.

Results

We found nine eligible systematic reviews. The quality of the evidence to support the current recommendation of HD initiation for most very elderly patients is very low. There is significant uncertainty in the balance of benefits and risks, patient preference, and whether default HD in this patient population is a wise use of resources.

Conclusion

Following the GRADE framework, recommendation for HD in this population would be weak. This means it should not be considered standard of care and should only be started based on the well-informed patient’s values and preferences. More studies are needed to delineate the true treatment effect and to guide future practice and policy.

Pre-emptive kidney transplantation to improve survival in patients with type 1 diabetes and imminent risk of ESRD

Despite significant improvements in the treatment of diabetic nephropathy over the past 20 years, patients with type 1 diabetes are at high risk of developing end-stage renal disease and high mortality once end-stage renal disease develops. Type 1 diabetic patients treated with predialysis (pre-emptive) transplantation have a lower death rate than type 1 diabetic patients treated with dialysis. Living donor kidney transplantation is possible before starting dialysis and is associated with better kidney and patient outcomes as compared with transplantation while on dialysis. In addition, a variety of potential donors can be used, not just young, well-matched family members. Through paired kidney donation, blood group ABO-incompatible transplants and transplants across the barrier of anti-human leukocyte antigen antibodies, diabetic patients can receive living donor kidney transplants even if their intended donor is not a good match for them. Despite these expanded options making living donation possible, only a minority of type 1 diabetic patients receive a pre-emptive kidney transplant. Multiple barriers remain that prevent type 1 diabetic patients from enjoying the reduced risk of death afforded by a pre-emptive kidney transplant, including lack of knowledge by primary care physicians, endocrinologists, and nephrologists; late referral for transplantation; patient and family misconceptions about timing of transplantation; and who can be a donor. The vast majority of type 1 diabetic patients are listed for kidney transplantation after the initiation of dialysis. Of these patients, thousands subsequently receive a live donor kidney transplant. We believe that the appropriate agencies and societies should address the barriers to pre-emptive kidney transplantation through nationwide educational initiatives and study the causes of failure to be transplanted before dialysis initiation.

Perceptions de l’arrêt de la dialyse et des traitements de maintien de la vie chez la clientèle québécoise en hémodialyse hospitalière: comparaison selon l’âge

The End-Stage Renal Disease population is aging. Considering that hemodialysis is a treatment that maintains and prolongs life, this descriptive-comparative study looks at the perceptions of patients according to age group -<65 years, n=121 and ≥65 years, n=123, as it pertains to dialysis treatment cessation and life-sustaining treatments.Results:Older patients are more indecisive as to what dialysis treatment cessation may actually represent for them (p=0,01). They expressed a greater need for support from the health care team if they decided to stop dialysis treatments (p=0,02); a greater involvement from the physician (p=0,04); and, in the event patients could not take part in end-of-life decision-making, they would give priority to the wishes of loved ones instead of their own wishes (p=0,01).Conclusion:Advanced care planning is necessary to demystify hemodialysis withdrawal and to support patients and their loved ones through this process.

The timing of dialysis and kidney transplantation in type 1 diabetes

Despite significant improvements in the treatment of diabetic nephropathy over the last 20 years, patients with type 1 diabetes are at high risk of developing end-stage renal disease (ESRD) and high mortality once ESRD develops. The timing of dialysis initiation has occurred earlier over the years, but a recent study has led to a re-evaluation of that approach. People with type 1 diabetes treated with pre-dialysis (pre-emptive) transplantation have a lower death rate than people with type 1 diabetes treated with dialysis. Living donor kidney transplantation is possible before starting dialysis and is associated with better kidney and patient outcomes as compared to transplantation while on dialysis. Multiple barriers remain that prevent people with type 1 diabetes from enjoying the reduced risk of death afforded by a pre-emptive kidney transplant, including lack of knowledge by primary care physicians, endocrinologists and nephrologists, late referral for transplantation, patient and family misconceptions about timing of transplantation and who can be a donor. New data on both the optimal time to initiate dialysis or to pursue transplantation will be reviewed.

Palliative medicine referral in patients undergoing continuous renal replacement therapy for acute kidney injury

BACKGROUND

Referral patterns for palliative medicine consultation (PMC) by intensivists for patients requiring continuous renal replacement therapy (CRRT) have not been studied.

METHODS

We retrospectively analyzed clinical data on patients who received CRRT in a tertiary referral center between 1999 and 2006 to determine timeliness and effectiveness of PMC referrals and mortality rate as a surrogate for safety among patients receiving CRRT for acute kidney injury.

RESULTS

Over one-fifth (21.1%) of the 230 CRRT patients studied were referred for PMC (n = 55). PMC was requested on average after median of 15 hospital and 13 intensive care unit (ICU) days. Multivariate regression analysis revealed no association between mortality risk and PMC. Total hospital length of stay for patients who died after PMC referral was 18.5 (95% CI = 15-25) days compared with 12.5 days (95% CI = 9-17) for patients who died without PMC referral. ICU care for patients who died and received PMC was longer than for patients with no PMC [11.5 (95% CI = 9-15) days vs. 7.0 (95% CI = 6-9) days, p < 0.01]. CRRT duration was longer for patients who died and received PMC referral than for those without PMC [5.5 (95% CI = 4-8) vs. 3.0 (95% CI = 3-4) days; p < 0.01].

CONCLUSIONS

PMC was safe, but referrals were delayed and ineffective in optimizing the utilization of intensive care in patients receiving CRRT. A proactive, "triggered" referral process will likely be necessary to improve timeliness of PMC and reduce duration of non-beneficial life-sustaining therapies.

Pain in chronic kidney disease: prevalence, cause and management

Pain is an unpleasant sensory and emotional experience and is the most common symptom experienced by renal patients. It can be caused by primary co-morbid diseases, renal replacement therapies, medication or treatment side effects, and its intensity varies from moderate to severe. Pain management in renal patients is difficult, since the distance between pain relief and toxicity is very small. This paper will provide an algorithm for pain management proposed using paracetamol, nonsteroid anti-inflamatory drugs (NSAIDs), mild and stronger opioids as well as complementary techniques. Quality of Life (QoL) and overall enhancement of the patient experience through better pain management are also discussed. To improve pain management it is essential that nurses recognise that they have direct responsibilities related to pain assessment and tailoring of opioid analgesics and better and more detailed education.

The effect of oral methadone on the QTc interval in advanced cancer patients: a prospective pilot study

BACKGROUND

Recent reports suggest that high doses of methadone may prolong QTc interval and occasionally cause torsades de pointes; however, few of these studies involved the palliative care population.

OBJECTIVE

The purpose of this study was to determine the effect of initiation of methadone on QTc interval in patients with cancer pain seen at the palliative care setting.

METHODS

We enrolled 100 patients with cancer in this prospective study. Patients were followed clinically and electrocardiographically for QTc changes at baseline, 2, 4, and 8 weeks. Contributing factors for QTc prolongation such as medications, cardiovascular diseases, and electrolytes disturbances were documented. QTc prolongation was defined as greater than 430 ms in males and greater than 450 ms in females, and significant QTc prolongation was defined as QTc interval greater than 25% increase from baseline or 500 ms or more.

RESULTS

Electrocardiographic (ECG) assessments were available for 100, 64, 41, and 27 patients at baseline, 2-, 4-, and 8-week follow-up, respectively. At baseline prior to initiation of methadone, 28 (28%) patients had QTc prolongation. Clinically significant increase in QTc occurred in only 1 of 64 (1.6%) patients at week 2, and none at weeks 4 and 8. There was no clinical evidence of torsades de pointes, ventricular fibrillation, or sudden death. QTc prolongation was more frequent among patients with increased baseline QTc interval.

CONCLUSIONS

Baseline QTc prolongation was common, whereas significant QTc interval 500 ms or more after methadone initiation rarely occurred, with no evidence of clinically significant arrhythmias. This study supports the safety of methadone use for pain control in patients with advanced cancer in the palliative care setting.

Predicting six-month mortality for patients who are on maintenance hemodialysis

BACKGROUND AND OBJECTIVES

Prognostic information is rarely conveyed by nephrologists because of clinical uncertainty about accuracy. The objective of this study was to develop an integrated prognostic model of 6-mo survival for patients who receive hemodialysis (HD).

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

A short-term prognostic model was developed using prospective data from a derivation cohort of 512 patients who were receiving HD at five dialysis clinics. Patient charts were reviewed for actuarial predictors (e.g., Charlson Comorbidity), and nephrologists answered the "surprise" question (SQ), "Would I be surprised if this patient died within the next 6 mo?" Survival was monitored for up to 24 mo. The prognostic model was tested with a validation cohort of 514 patients from eight clinics.

RESULTS

In a Cox multivariate analysis of the derivation cohort, five variables were independently associated with early mortality: Older age (hazard ratio [HR] for a 10-yr increase 1.36; 95% confidence interval [CI] 1.17 to 1.57), dementia (HR 2.24; 95% CI 1.11 to 4.48), peripheral vascular disease (HR 1.88; 95% CI 1.24 to 2.84), decreased albumin (HR for a 1-U increase 0.27; 95% CI 0.15 to 0.50), and SQ (HR 2.71; 95% CI 1.76 to 4.17). Area under the curve for the resulting prognostic model predictions of 6-mo mortality were 0.87 (95% CI 0.82 to 0.92) in the derivation cohort and 0.80 (95% CI 0.73 to 0.88) in the validation cohort.

CONCLUSIONS

An integrated 6-mo prognostic tool was developed and validated for the HD population. The instrument may be of value for researchers and clinicians to improve end-of-life care by providing more accurate prognostic information.