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.

Palliative care in end-stage kidney disease.

Patients with end-stage kidney disease have significantly increased morbidity and mortality. While greater attention has been focused on advanced care planning, end-of-life decisions, conservative therapy and withdrawal from dialysis these must be supported by adequate palliative care incorporating symptom control. With the increase in the elderly, with their inherent comorbidities, accepted onto dialysis, patients, their nephrologists, families and multidisciplinary teams, are often faced with end-of-life decisions and the provision of palliative care. While dialysis may offer a better quality and quantity of life compared with conservative management, this may not always be the case; hence the patient is entitled to be well-informed of all options and potential outcomes before embarking on such therapy. They should be assured of adequate symptom control and palliative care whichever option is selected. No randomized controlled trials have been conducted in this area and only a small number of observational studies provide guidance; thus predicting which patients will have poor outcomes is problematic. Those undertaking dialysis may benefit from being fully aware of their choices between active and conservative treatment should their functional status seriously deteriorate and this should be shared with caregivers. This clarifies treatment pathways and reduces the ambiguity surrounding decision making. If conservative therapy or withdrawal from dialysis is chosen, each should be supported by palliative care. The objective of this review is to summarize published studies and evidence-based guidelines, core curricula, position statements, standards and tools in palliative care in end-stage kidney disease.