A Palliative Approach to Dialysis Care

Abstract

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.

The Ethics of Chronic Dialysis for the Older Patient

“…Physicians and other health care providers bring personal values and biases that can shape the approach to how difficult treatment discussions are broached (51). They are also influenced by incentives such as reimbursement adjustments based on process and quality metrics (29,52). It is important for clinicians to recognize and set aside those agendas to meet the needs of the patient and/or their surrogate(s).…”

“…Also, the calculator for risk of progression of CKD to ESRD can help determine timing (24). Too strict an adherence to guideline-based care and quality metrics without discrimination by clinical status and goals of care can hinder a more nuanced and patient-centered approach to care (29,52,59).…”

Implantable Ventricular Assist Device Use and Outcomes in People With End‐Stage Renal Disease

“…An American Heart Association scientific statement suggests routine palliative care physician consultation before institution of mechanical circulatory support, and The Joint Commission requires palliative care specialist involvement for VAD destination therapy 13, 14, 15. Organizations and authors are also increasingly recognizing the important role palliative care plays in ESRD, and especially congestive heart failure complicating ESRD 16, 17. People with ESRD, and those with congestive heart failure, may receive lower quality end‐of‐life care than those with other life‐limiting conditions 18…”

Four Plus Forty-Four

“…Several recent publications advocate for a patient-focused approach to care (18,(22)(23)(24), and there have been a number of events or changes that have occurred in the past 18 months (a few are listed below).…”

“…Advocacy groups at the Provincial British Columbia Renal Agency have now established funding structures to allow for coverage to flow to those opting for a conservative care pathway. Two special interest groups, the ASN Dialysis Advisory Group and the Geriatric Nephrology Advisory Group, have taken steps toward implementing symptom-focused dialysis care through a recent collaborative position paper (23). These advisory groups identified knowledge gaps in how dialysis care is currently provided and have proposed modified treatment protocols that may benefit those with limited life expectancy.…”