Palliative dialysis in hospice: A paradox or promising answer?

Abstract

LETTER TO THE EDITORDear Editor, End-stage renal disease (ESRD) patients have higher mortality, hospital admissions and invasive procedures towards the end of life. 1 However, many of them (82%) prioritise minimising suffering over life prolongation. Although twice as many patients prefer dying at home and inpatient hospice (65%) compared to hospital (27%), hospice utilisation remains lower for dialysis patients (20%) compared to those with cancer (55%) and heart failure (39%). 2 For patients continuing dialysis until death, hospice usage plummets further (18% versus 58%). 3 Dialysis seemingly contravenes traditional hospice tenets of prioritising comfort over life prolongation. The dilemma of withdrawing dialysis to enter hospice, or continue dialysis but forgo hospice, is a disservice to patients who are seeking a transition to comfort-driven care, yet would benefit symptomatically, psychologically and prognostically from dialysis.We describe a case of a patient on peritoneal dialysis (PD) with concomitant malignancy, who restarted PD in an inpatient hospice after initial dialysis withdrawal.The patient was a 78-year-old man with lung adenocarcinoma with metastases to brain and pleura. He was on PD for ESRD secondary to diabetic kidney disease.Seventeen days into second-line chemotherapy, he was admitted to hospital for delirium and functional decline. Considering the rapid deterioration, his oncologist advised for best supportive care and gave a prognosis of 3 months. He concurrently developed recurrent intradialytic hypotension, rendering PD unsafe. A goals-of-care discussion was conducted with his wife, and PD was withdrawn. Unfortunately, the patient's delirium prevented his participation in this discussion.He was transferred to our inpatient hospice, where his haemodynamics and confusion significantly improved. He could communicate his wishes coherently and consistently. He desired to continue PD until medically contraindicated, while shifting care goals towards prioritising comfort, as he was cognisant of the limited prognosis portended by his incurable malignancy. After discussion with his oncologist, nephrologist and palliative care physician, we restarted PD in our inpatient hospice.