Palliative Care for the ESRD
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Transcript of Palliative Care for the ESRD
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Palliative Care Palliative Care for the ESRD Patientfor the ESRD Patient
Alvin H. Moss, MDCenter for Health Ethics and Law
Section of NephrologyWest Virginia University
Palliative Care
End-of-Life/ Hospice Care
Relationship between Palliative Care and EOLC
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DefinitionDefinition
Palliative care is comprehensive, interdisciplinary care of patients and families facing a chronic or terminal illness focusing primarily on comfort and support.
Billings JA. Palliative Care. Recent Advances. BMJ2000:321:555-558.
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Palliative Care ApproachPalliative Care Approach
Pain and symptom managementPain and symptom management Communication-Advance care Communication-Advance care
planningplanning• DNRDNR• Advance DirectivesAdvance Directives
Psychosocial and spiritual supportPsychosocial and spiritual support Hospice referralHospice referral
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HospiceHospicePalliative CarePalliative Care
Curative / Remissive TherapyCurative / Remissive Therapy
Start Dialysis Death
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Patient’s ConcernsPatient’s ConcernsRegarding End-of-Life Regarding End-of-Life CareCare Receiving adequate pain and symptom Receiving adequate pain and symptom
controlcontrol Avoiding inappropriate prolongation of Avoiding inappropriate prolongation of
dyingdying Achieving a sense of controlAchieving a sense of control Relieving burden on loved onesRelieving burden on loved ones Strengthening relationships with loved Strengthening relationships with loved
onesonesSinger PA, et al. JAMA 1999; 281:163-168.
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Relevance to ESRDRelevance to ESRD Shortened life expectancyShortened life expectancy High symptom burdenHigh symptom burden Aging populationAging population
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ESRD Patient Probability of ESRD Patient Probability of SurvivalSurvival
Patient PopulationPatient Population Survival Survival (%)(%)
1-yr for all incident patients, unadjusted1-yr for all incident patients, unadjusted 79791-yr for incident patients >65 yrs, 1-yr for incident patients >65 yrs, unadjustedunadjusted
6565
2-yr for all incident patients, unadjusted2-yr for all incident patients, unadjusted 65652-yr for all incident patients >65 yrs, 2-yr for all incident patients >65 yrs, unadjunadj
4848
5-yr for all incident patients, unadjusted5-yr for all incident patients, unadjusted 38385-yr for incident patients >65 yrs, 5-yr for incident patients >65 yrs, unadjustedunadjusted
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10-yr for all incident patients, unadjusted10-yr for all incident patients, unadjusted 202010-yr for incident patients >65 yrs, 10-yr for incident patients >65 yrs, unadjustedunadjusted
33USRDS, 2004 Annual Data Report
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0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
Surv
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e (%
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2 Year 5 Year 10 Year
Survival Rates for Cancer and ESRD Patients
CancerESRD
Data from USRDS and NCI
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High Symptom BurdenHigh Symptom Burden HD patients median # of symptoms=9HD patients median # of symptoms=9 Pain in over 50%Pain in over 50% Associated with impaired HRQoLAssociated with impaired HRQoL Associated with depressionAssociated with depression
Weisbord, et al. JASN 2005:16:2487-2494
11110%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Perc
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Dry Skin Tired or Lack ofEnergy
Itching Bone or JointPain
Muscle Cramps
Prevalence of Individual Symptoms
Weisbord, JASN 2005;16:2487-2494
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Association Between Symptoms Association Between Symptoms and Quality of Life Measuresand Quality of Life Measures
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94.5
37.629 21.7
7.56.5 5.3
24.623.418.3
020406080
100120140160
MQOL TotalScore
MQOLPhysicalSubscale
QOL SingleItem Index
SWLS
no symptoms 1 symptom 2+ symptoms
Tot
al S
c ore
Tot
al S
c ore
Note: All results statistically significant, p values <.01Note: All results statistically significant, p values <.01
Kimmel, et al.AJKD 2003
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Aging PopulationAging Population Rising median age of dialysis populationRising median age of dialysis population
>50% over 65 yrs old>50% over 65 yrs old Over 79,000 dialysis patients die per yearOver 79,000 dialysis patients die per year ~20% die after decision to withdraw~20% die after decision to withdraw High percentage with comorbiditiesHigh percentage with comorbidities High in-hospital death-63%*High in-hospital death-63%*
* United States Renal Data System 2001-2002 cohort
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Would you be surprised if Would you be surprised if the patient died in the the patient died in the next year?next year?
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Prognostic Factor All (N=166)
"Yes" (N=130)
"No" (N=36) P value
McGill QOL Question 6.7±2.1 6.8±2.1 6.1±2.0 0.052
CCI Score 6.0±2.3 5.7±2.2 7.3±1.9 <0.001
Pain VAS Score 2.5±3.2 2.2±3.0 3.8±3.6 0.007
Karnofsky Performance Status 78.7±17.6 84.0±13.7 58.8±16.3 <0.001
Age (yrs) 65.9±15.8 63.4±16.2 75.1±9.8 <0.001
Kt/V 1.5±0.3 1.45±0.28 1.48±0.26 0.540
Hb (g/dL) 12.0±1.1 12.1±1.2 11.9±0.87 0.483
Serum Albumin 3.8±0.3 3.9±0.27 3.7±0.42 0.004
Male/Female 55/45 58/42 44/56 0.134
White/Non-white 90/10 76/94 24/6 0.072
Performance of “Surprise” Question in ESRD*
*Values are mean ± SD or %
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IncorporatingIncorporating Palliative Care Palliative Care into Your Dialysis Unitinto Your Dialysis Unit
Surprise question on rounds Educational in-services on palliative care topics Advance care planning Pain & symptom assessment and treatment protocols Communication of prognosis and changes in condition Referral to hospice when terminally ill QI with review of quality of death Memorial service
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Dialysis Withdrawal and Hospice Status of Deceased Patients USRDS 2001-2002 Cohort Dialysis Withdrawal and Hospice Status
Deceased Patients(N=115,239)
Percent Mean Age in Years
Hospice Yes 15,565 13.5 73.4 ± 11.0 *Hospice No 99,674 86.5 68.6 ± 13.4Withdrawal Yes 25,075 21.8 72.7 ± 11.8 ** Hospice Yes 10,518 41.9 73.9 ± 10.6 Hospice No 14,557 58.1 71.7 ± 12.3Withdrawal No 81,624 70.8 68.0 ± 13.4 Hospice Yes 2,751 3.4 71.7 ± 11.7 Hospice No 78,873 96.6 67.9 ± 13.5Withdrawal Status Unknown
8,540 7.4 71.1 ± 13.2
Murray and Moss, ASN 2004
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Death After Dialysis Withdrawal: Death After Dialysis Withdrawal: Are Patients Appropriate for Are Patients Appropriate for Hospice?Hospice?
StudyStudy YearYear NN MeanMean RangeRange
Neu & Neu & KjellstrandKjellstrand 19861986 155155 8.1 days8.1 days 1 - 291 - 29
Sekkarie & Sekkarie & MossMoss 19981998 6060 12 days12 days 0 - 1500 - 150
Cohen et alCohen et al 20002000 126126 8.2 days8.2 days 1 - 461 - 46
Ethical and Legal IssuesEthical and Legal Issues
Alvin H. Moss, MDCenter for Health Ethics and Law
Section of NephrologyWest Virginia University
ObjectivesObjectives
Present the recommendations of the RPA/ASN on when it is appropriate to withhold and stop dialysis
Discuss the ethical justifications Analyze 3 cases of dialysis patients at the end
of life in which decision-making is challenging
A Recent Case in Point A Recent Case in Point
Mrs. G is a 78 year old woman was referred by Mrs. G is a 78 year old woman was referred by her primary MD for evaluation of CKD with her primary MD for evaluation of CKD with worsening function. She had a 20 year history worsening function. She had a 20 year history of DM complicated by PVD, requiring toe of DM complicated by PVD, requiring toe amputation. She had multiple other comorbid amputation. She had multiple other comorbid illnesses including hypertension, cryptogenic illnesses including hypertension, cryptogenic cirrhosis with liver failure, pancytopenia, CHF, cirrhosis with liver failure, pancytopenia, CHF, and a history of massive GI bleeding from and a history of massive GI bleeding from esophageal varices a year ago. esophageal varices a year ago.
A Recent Case in Point A Recent Case in Point
The patient required assistance with all ADL except feeding and was residing in a NH. She had only a sister whom she named her medical power of attorney representative. She had decision-making capacity. Lab data revealed an estimated GFR of 15 ml/min, and a serum albumin of 2.8 mg/dl. It was obvious she would progress to ESRD soon. The patient made it clear that despite her poor prognosis, she wanted hemodialysis when needed.
When should we not start?When should we not start?When should we stop?When should we stop?
Clinical Practice Guideline #2
Shared Decision-MakingShared Decision-Making in the in theAppropriate Initiation ofAppropriate Initiation of and and Withdrawal from DialysisWithdrawal from Dialysis
Clinical Practice Guideline (CPG)Clinical Practice Guideline (CPG)
A systematically developed statement to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances (IOM).
RPA/ASN GuidelineRPA/ASN Guideline
Nine recommendationsNine recommendations Rationale for each recommendationRationale for each recommendation 25 prognostic tables25 prognostic tables 302 references302 references Consensus of AAKP, RPA, ASN, ANNA,Consensus of AAKP, RPA, ASN, ANNA,
ASPN, NKF, NRAA, ESRD ForumASPN, NKF, NRAA, ESRD Forum
How Recommendations Were How Recommendations Were Developed?Developed?
The working group formulated specific The working group formulated specific guideline recommendations taking into guideline recommendations taking into account…account…– Ethical principlesEthical principles– Case and statutory lawCase and statutory law– Research Research
Peer review by stakeholdersPeer review by stakeholders
Ethical PrinciplesEthical Principles
Respect for patient autonomyRespect for patient autonomy BeneficenceBeneficence NonmaleficenceNonmaleficence JusticeJustice Professional integrityProfessional integrity
Topics to be ConsideredTopics to be Consideredin Ethical Analysisin Ethical Analysis
Medical IndicationsMedical Indications Patient PreferencesPatient Preferences Quality of LifeQuality of Life Contextual FeaturesContextual Features
Jonsen, Siegler, Winslade. Clinical Ethics, 5th ed.2002
Medical IndicationsMedical Indications
Diagnostic and therapeutic Diagnostic and therapeutic interventions (e.g., dialysis) are interventions (e.g., dialysis) are deemed to be indicated if the deemed to be indicated if the expected medical benefits justify expected medical benefits justify the risks.the risks.
Recommendation #1:Recommendation #1:Shared Decision-MakingShared Decision-Making
A patient-physician relationship that promotes shared decision-making is recommended for all patients with either ARF or ESRD. Participants in shared decision-making should involve at a minimum the patient and the physician. If a patient lacks decision-making capacity, decisions should involve the legal agent. With the patient’s consent, shared decision-making may include family members or friends and other members of the renal care team.
Recommendation #2:Recommendation #2:Informed Consent or RefusalInformed Consent or Refusal
Physicians should fully inform patients about their diagnosis, prognosis, and all treatment options, including: 1) available dialysis modalities, 2) not starting dialysis and continuing conservative management which should include end-of-life care, 3) a time-limited trial of dialysis, and 4) stopping dialysis and receiving end-of-life care. Choices among options should be made by patients or, if patients lack decision-making capacity, their designated legal agents. Their decisions should be informed and voluntary…
Recommendation #3Recommendation #3Estimating PrognosisEstimating Prognosis
To facilitate informed decisions about startingdialysis for either ARF or ESRD, discussions should occur with the patient or legal agent about life expectancy and quality of life.…All patients requiring dialysis should have theirchances for survival estimated, with the realization that the ability to predict survival inthe individual patient is difficult and imprecise.The estimates should be discussed with the patient or legal agent, patient’s family, and among the medical team.
Predictors of Poor PrognosisPredictors of Poor Prognosisfor ESRD Patientsfor ESRD Patients
AgeAgeFunctional abilityFunctional abilityNutritional statusNutritional statusComorbid Illnesses - diabetes, MI, PVDComorbid Illnesses - diabetes, MI, PVD
RPA/ASN. Shared Decision-Making in the Appropriate Initiation of and Withdrawal from Dialysis. 2000.
Nutritional StatusNutritional Status
Serum albumin < 3.5 g/dL Serum albumin < 3.5 g/dL ≈≈ 50% 1 yr mortality 50% 1 yr mortality Serum albumin < 2.5 g/dL vs > 4.0 g/dL confers Serum albumin < 2.5 g/dL vs > 4.0 g/dL confers
7.45 greater risk of early death7.45 greater risk of early death
RPA/ASN. Shared Decision-Making in the Appropriate Initiation of and Withdrawal from Dialysis. 2000.
Indicators of Poor PrognosisIndicators of Poor Prognosis
Severe functional impairment confers 3.46 times Severe functional impairment confers 3.46 times greater risk of early deathgreater risk of early death
Acute MI associated with 60% 1 yr mortalityAcute MI associated with 60% 1 yr mortality AKA associated with 73% 1 yr mortalityAKA associated with 73% 1 yr mortality
RPA/ASN. Shared Decision-Making in the Appropriate Initiation of and Withdrawal from Dialysis. 2000.
Charlson Comorbidity IndexCharlson Comorbidity Index1 point1 point MI, CHF, PVD, CVA, MI, CHF, PVD, CVA,
Dementia, COPD, PUD,Dementia, COPD, PUD,Mild liver diseaseMild liver disease
2 points2 points Mod-severe CKD, CA w/o metsMod-severe CKD, CA w/o metsDM with end-organ damageDM with end-organ damage
3 points3 points Mod-severe liver diseaseMod-severe liver disease6 points6 points Metastatic solid CAMetastatic solid CA
AIDSAIDS1 point1 point Each decade in age > 40 yearsEach decade in age > 40 years
Beddhu et at. Am J Med 2000;108:609-613
Calculated CCI for Mrs. GCalculated CCI for Mrs. G1 point1 point Congestive Heart FailureCongestive Heart Failure
1 point1 point Peripheral Vascular DiseasePeripheral Vascular Disease
2 points2 points Diabetes with end-organ damageDiabetes with end-organ damage
2 points2 points Severe kidney diseaseSevere kidney disease
3 points3 points Age correction (3 decades older than 40 yrs)Age correction (3 decades older than 40 yrs)
3 points3 points Severe liver diseaseSevere liver disease
TotalTotal 12 points12 points
Prognosis from CCIPrognosis from CCI
Low scoreLow score Mod ScoreMod Score High High ScoreScore
Very High Very High ScoreScore
CCI PointsCCI Points < or =3< or =3 4-54-5 6-76-7 = or >8= or >8
Mortality Mortality (per pt-yr)(per pt-yr)
0.030.03 0.130.13 0.270.27 0.490.49
Who Should Not Be DialyzedWho Should Not Be Dialyzed Patients (legal agents) who refuse dialysis Patients (legal agents) who refuse dialysis Patients with profound neurological impairmentPatients with profound neurological impairment Patients terminally ill from a non-renal causePatients terminally ill from a non-renal cause Patients whose condition precludes the technical Patients whose condition precludes the technical
process of dialysis-advanced dementia and process of dialysis-advanced dementia and severe mental disabilitysevere mental disability
RPA/ASN. Shared Decision-Making in the Appropriate Initiation of and Withdrawal from Dialysis. 2000.
Possible RecommendationsPossible Recommendationsto Mrs. Gto Mrs. G
Start dialysis without any limitationsStart dialysis without any limitationsTime-limited trial of dialysisTime-limited trial of dialysisRefuse to start dialysisRefuse to start dialysis
Recommendation #8Recommendation #8Time-Limited TrialsTime-Limited Trials
For patients requiring dialysis, but who have an uncertain prognosis, or for whom a consensus cannot be reached about providing dialysis, nephrologists should consider offering a time-limited trial of dialysis.
The Daughter Rescinded the DNR OrderThe Daughter Rescinded the DNR Order A 65-year-old widow with a history of DM, hypertension, and TIA was started on HD for DN. She was cognitively intact, cooperative, compliant, and able to deal with her diagnosis of ESRD. She used the Wheelchair Van Service because she did not want to be a burden. She had family support, primarily from her daughter. Two years after starting dialysis, she signed a DNR order and a Health Care Proxy, naming her daughter. About 2 weeks later, a CT scan done for mental status changes revealed multiple areas of infarction. Subsequently, she had numerous admissions to the hospital for fluid overload. Dialysis was increased to 4 times a week. Her mental status deteriorated further, and she was transferred to a NH.
Subsequently, she was noted to come from the NH to the dialysis facility very agitated. She would upset other patients. She became progressively problematic, and medications were tried to control her inappropriate yelling and screaming, to no avail. She was transferred to the hospital unit where she could be treated in isolation and observed more closely. She was starting to get out of her chair during treatments and pull out dialysis needles. Her daughter was repeatedly informed of her behavior, but her response was to rescind the DNR order.
The patient’s transfer to the hospital unit angered the daughter; she did not accept that it was in the patient’s best interest. The patient became more demented. She refused to eat; she lost 60 lbs down to 70 lbs. The daughter avoided meetings to discuss long-range planning. Yet she made it clear that she did not wish to stop dialysis. She asked about a feeding tube to increase the patient’s weight. The patient had no swallowing or GI problems to justify PEG placement. The patient continued to do poorly and died 5 years after starting dialysis and 14 months after becoming incapacitated.
Case Courtesy of Rocco C. Venuto, MD
The Daughter Rescinded The Daughter Rescinded the DNR Orderthe DNR Order
Medical IndicationsMedical Indications– Dialysis – Recommendation No. 7 appliesDialysis – Recommendation No. 7 applies– CPR - <5% chance of survival – ESRD, strokes, CPR - <5% chance of survival – ESRD, strokes,
dementia, malnutritiondementia, malnutrition Patient PreferencesPatient Preferences
– No CPR – failure to respect patient autonomyNo CPR – failure to respect patient autonomy– ADAD
• Daughter is proxyDaughter is proxy• Wishes re: withdrawal of dialysis unknownWishes re: withdrawal of dialysis unknown
Recommendation #7Recommendation #7Special Patient GroupsSpecial Patient Groups
It is reasonable to consider not initiating or It is reasonable to consider not initiating or withdrawing dialysis for patients with ARF withdrawing dialysis for patients with ARF or ESRD who have a terminal condition or ESRD who have a terminal condition from a nonrenal cause or whose medical from a nonrenal cause or whose medical condition precludes the technical process condition precludes the technical process of dialysis.of dialysis.
Recommendation #5Recommendation #5 Advance DirectivesAdvance Directives
The renal care team should attempt to The renal care team should attempt to obtain written advance directives from obtain written advance directives from all dialysis patients. These advance all dialysis patients. These advance directives should be honored.directives should be honored.
Failure of Advance Care Planning to Elicit Patients’ Preferences for
Withdrawal From Dialysis
Patients who had completed a living will and proxy were most likely to have discussed EOLC, but stopping dialysis was the least often discussed intervention, even in this patient subset. Sixty-nine percent had discussed MV; 55%, tube feedings; 43%, CPR; and only 31% had discussed stopping dialysis (all P < 0.001). Although withdrawal from dialysis is relatively common, it is rarely discussed in advance care planning by dialysis patients. Dialysis unit staff and nephrologists should address issues involving withdrawal from dialysis with their chronic dialysis patients. Am J Kidney Dis 1999; 33: pp 688-693
The Daughter Rescinded the DNR The Daughter Rescinded the DNR OrderOrder
QOLQOL– Multiple admissions for fluid overloadMultiple admissions for fluid overload– AgitationAgitation– Severe dementia with cachexiaSevere dementia with cachexia– Failure to thriveFailure to thrive
The Daughter Rescinded the DNR The Daughter Rescinded the DNR OrderOrder
ContextualContextual– Daughter ethically and legally ought not override Daughter ethically and legally ought not override
patient’s wishespatient’s wishes– NY lawNY law– Other patients in unit – use of sitter Other patients in unit – use of sitter – Daughter’s emotional and spiritual needsDaughter’s emotional and spiritual needs
Emotional and Spiritual IssuesEmotional and Spiritual Issues
“I am convinced that what really makes these decisions ‘hard choices’ has little to do with the medical, legal, ethical, or moral aspects of the decision process. The real struggles are emotional and spiritual. People wrestle with letting go. These are decisions of the heart, not just the head.”
Chaplain Hank Dunn, Hard Choices for Loving People, 4th ed., 2002
Spiritual Issues Spiritual Issues in Withdrawal of Dialysisin Withdrawal of Dialysis
Once the treatment is no longer medically indicated, the real issue is whether the patient or family (or physician) can “let go.”
“Those who choose such life-prolonging treatments for failing patients do so primarily out of an inability to let go and not out of moral necessity or medical appropriateness.”
Chaplain Hank Dunn, Hard Choices for Loving People, 4th ed.,2002
What should you do?What should you do?
Not allow the daughter to rescind the patient’s Not allow the daughter to rescind the patient’s DNR order to respect patient autonomyDNR order to respect patient autonomy
Require the daughter to sit with the patient during Require the daughter to sit with the patient during treatmentstreatments
Ask the daughter what the mother would want if Ask the daughter what the mother would want if she were able to sayshe were able to say
Instruct the daughter on her ethical and legal role Instruct the daughter on her ethical and legal role as durable power of attorney for health careas durable power of attorney for health care
Provide support to the daughterProvide support to the daughter
A 78 yr old woman presented with a 3 day hx of A 78 yr old woman presented with a 3 day hx of increasing SOB due to pulmonary edema. She had CKD increasing SOB due to pulmonary edema. She had CKD with a serum Cr of 12. CXR showed a large R hilar with a serum Cr of 12. CXR showed a large R hilar shadow suggestive of carcinoma of the lung. She shadow suggestive of carcinoma of the lung. She received hemodialysis pending work-up. Investigations received hemodialysis pending work-up. Investigations showed squamous cell carcinoma of the R lung; she was showed squamous cell carcinoma of the R lung; she was referred for radiotherapy. referred for radiotherapy.
With dialysis her dyspnea regressed, and she felt well. With dialysis her dyspnea regressed, and she felt well. There were no symptoms from the carcinoma. She There were no symptoms from the carcinoma. She requested to continue dialysis so that she could visit her requested to continue dialysis so that she could visit her extended family and tidy her affairs. She said she would extended family and tidy her affairs. She said she would wish to stop dialysis once she developed symptoms wish to stop dialysis once she developed symptoms from the cancer. After 7 wks of dialysis she developed from the cancer. After 7 wks of dialysis she developed dyspnea and pain related to her cancer. She withdrew dyspnea and pain related to her cancer. She withdrew from dialysis and received palliative care until her death.from dialysis and received palliative care until her death.
Short-term Benefit in a Terminally Ill Patient
Reasons to Dialyze Reasons to Dialyze Terminally Ill PatientsTerminally Ill Patients
Short-term benefit for competent patientShort-term benefit for competent patient Time-limited trial of dialysis to help patient and Time-limited trial of dialysis to help patient and
family understand burdens of treatmentfamily understand burdens of treatment
There is an option for ESRD patients There is an option for ESRD patients who choose to stop or not to start who choose to stop or not to start dialysis: dialysis: continuedcontinued palliative care. palliative care.
Recommendation #9 Recommendation #9 Palliative CarePalliative Care
All patients who decide to forgo dialysis (or for whom such a decision is made) should receive continued palliative care. With the patient’s consent, persons with expertise in such care, such as hospice health care professionals, should be involved in managing the medical, psychosocial, and spiritual aspects of end-of-life care for these patients. Patients should be offered the option of dying where they prefer including at home with hospice care. Bereavement support should be offered to patients’ families.
Shared Decision-Making Shared Decision-Making in the Appropriate Initiation ofin the Appropriate Initiation ofand Withdrawal from Dialysisand Withdrawal from Dialysis
[email protected] 301.468.3515
Robert Wood Johnson FoundationRobert Wood Johnson FoundationESRD Peer Workgroup ReportESRD Peer Workgroup Report
www.promotingexcellence.org/esrd/www.promotingexcellence.org/esrd/
Completing the Continuum of Nephrology Care
ConclusionsConclusions
Recent research enables us to predict more Recent research enables us to predict more accurately the patients for whom the burdens accurately the patients for whom the burdens of dialysis will likely outweigh the benefits.of dialysis will likely outweigh the benefits.
Dialysis decision-making should remain case-Dialysis decision-making should remain case-by-case.by-case.
New nephrology guidelines are helpful in New nephrology guidelines are helpful in decision-making.decision-making.
Professional integrity requires us to respect Professional integrity requires us to respect patients’ wishes even when families want to patients’ wishes even when families want to override them and to do no harm.override them and to do no harm.