This popular session was packed with interest and enthusiasm for how best to provide patient-care in elderly patients with kidney disease. Vanessa Grubs, from University of California at San Francisco, and I moderated a lively discussion from four experts addressing palliative care, dialysis decision-making, and transplantation for this unique population.
The first speaker Dr. Manjula Kurella Tamura from the Vetarans Affairs Palo Alto Health Care System and Stanford University introduced a broad application of palliative care in “Promoting Palliative Care for Patients with ESRD.” Dr. Tamura eloquently made the argument that ESRD patients have high symptom needs, increased intensity of care at end of life and high caregiver needs. She applied the domains of palliative care to address these unmet needs including the following:
- Improving physical and psychological symptoms
- Providing advance care planning to ensure patients receive treatment that aligns with patient goals
- Improved bereavement services to attend to the needs of bereaved caregivers
Importantly, Dr. Tamura described that palliative care can occur concurrently alongside curative treatments such as dialysis and transplantation. Its focus is on improving the quality of one’s life.
She highlighted a recent advance care planning study SPIRIT of 210 patient-surrogate dyads randomized to ACP intervention versus usual care. The intervention resulted in increased congruence in goals of care and surrogate decision-making confidence, decreased decisional conflict, and decreased anxiety, depression, and post traumatic stress disease symptoms in bereaved surrogates.
The take home message from Dr. Tamura’s talk: there aren’t enough palliative care providers and services to care for the needs of ESRD patients. Nephrology providers need to learn these skills! Ways to identify patients who are likely to benefit from palliative care services:
- New starts (patients starting dialysis)
- High utilizers (those with recurrent hospitalizations)
- Answer of “No” to the Surprise Question
- Screening for symptoms
Dr. Alvin “Woody” Moss from West Virginia University addressed the “Ethics of End-of-Life Care in ESRD” in a spirited case-based discussion of shared decision-making in dialysis decision-making. He supported the need for patient-centered preparation through a recent article from Health Affairs (Sept 2015) called “Medical Myths: Unprepared for the End Stages of End-Stage Kidney Disease” which candidly describes the difficult end of life experience for patient and family after deciding not to start dialysis.
Dr. Moss underscored the role of prognostication to guide shared decision-making discussions with patients and families facing dialysis decisions. Citing the Renal Physician Association guideline, he outlined poor prognostic factors associated with dialysis in patients with two or more of the following:
- ≥ 75 years
- High comorbidity scores (answering “No” to the Surprise Question)
- Marked functional impairment
- Severe chronic malnutrition
He reinforced the need for patient-centered care for those who have elected dialysis through highlighting the recent article by Dr. Grubbs “A Palliative Approach to Dialysis Care: A Patient-Centered Transition to the End of Life.” Dr. Moss argued for changes in existing dialysis metrics to include more patient-centered outcomes such as goals of care, quality of life, symptom management, and completion of advance care planning.
Dr. Michael Germain from Baystate Medical Center and Tufts University School of Medicine was tasked with describing “Aggressive Care for Older Dialysis Patients: From Intervention to Rehab.” Dr. Germain reframed the concept of aggressive care to include everything done that is likely to do more good than harm and is consistent with the patient’s goals. In this sense, palliative care should be an aggressive care option.
Dr. Germain further made a case for the role of aggressive rehabilitation for geriatric hemodialysis patients. He described a quality improvement study of geriatric patients with functional decline and high comorbidities referred to an interdisciplinary inpatient rehabilitation program. After median of 48.5 days, almost 70% of patients were discharged home with 82% of patients meeting some of their rehabilitation goals.
Dr. John Gill from University of British Columbia and St. Paul’s Hospital, Vancouver, B.C., tackled the topic of transplantation in the elderly. He concisely described the new deceased donor allocation and its impact on elderly patients seeking transplantation. The impact of the new deceased kidney allocation system which stratifies kidneys based on Kidney Donor Profile Index and expected post-transplant survival. These changes will ultimately lead to increased transplants in those 10-49 years of age with fewer transplants going to those over 50 years. Hence older patients will likely have less access to non-ECD kidneys.
Dr. Gill applied the new allocation system to a case of a healthy 70 year old gentleman with ESRD on dialysis. He highlighted the survival advantage in elderly patients (age ≥70 years) comparing those who were transplanted to those on the wait-list (Rao et al). Overall with a registry of 5,667 elderly patients on the transplant list, transplanted patients had a 41% lower risk of death compared to those wait-listed.
Dr. Gills’ take home point: Almost half of patients older than 60 die waiting for a deceased donor transplant. Dr. Gill argued that the best allograft options include the fastest and safest options. Elderly patients may benefit most from living donor transplantation (including older donors up to 65 years) especially those whose projected survival is shorter than the expected wait time for transplant and those with high peri-operative risk (Gill et al).
My take-home: Patient-centered care translates into care that matters most to patients. This care spans the kidney disease trajectory to include renal replacement options such as dialysis and transplantation, management of distressing symptoms, and preparation for end of life for patients and caregivers.
Post by Dr. Jane Schell, AJKD Blog Contributor.
Check out all of AJKD Blog’s coverage of Kidney Week 2015!