The world of renal medicine has witnessed revolutionary advancements since the first successful dialysis in 1945. Over the past seven decades, with the efforts of pioneers such as Dr. Willem Kolff, the “father of dialysis,” and the widespread use of dialysis for treatment of end stage renal disease (ESRD), millions of patients with renal failure have been offered a second chance to celebrate life.
However, recent data demonstrate a lack of a survival benefit of dialysis in older patients with multiple comorbidities. Despite this, older patients who have poor prognoses are routinely initiated and continued on dialysis without a discussion of realistic expectations. In fact, patients over 75 years of age are the fastest growing population initiating dialysis.
Considering the high mortality and symptom burden in patients with chronic kidney disease (CKD), there is growing awareness among nephrologists of a need for palliative care in patients with CKD and ESRD. Additionally, the unmet needs, with respect to end-of-life care, of patients with advanced CKD underscore the call to incorporate palliative care training in nephrology fellowships and the current lack thereof.
“…If a cardiac surgeon does an open heart [surgery] in an 85-year old and the patient develops renal failure tomorrow how can I come and say, ‘I don’t want to dialyze this patient because she’s 85,’ or something like that. So what am I supposed to do at that time?” [American nephrologist]
The quote above is from a recent qualitative study published in AJKD. Grubbs et al sought to identify nephrologists’ attitudes on factors that influence dialysis decision-making. The authors interviewed practicing adult nephrologists from both the Unites States and England regarding their perspectives involving foregoing or withdrawing dialysis. Nephrologists in both countries believed that the lack of palliative care training and the lack of prognostication tools and evidence-based guidelines in end-of-life care were significant barriers. Nephrologists practicing in the US also felt that the financial incentive to dialyze and the perceived lack of time and reimbursement for lengthy conversations with patients involving dialysis decision-making was a major factor.
Availability of hospice and palliative care services was identified as significant facilitators for foregoing or withdrawal of dialysis. However, nephrologists in the US described limited access to these services in the outpatient settings whereas those in England reported adequate access in both settings. See excerpt from Table 2:
This study demonstrates results in accordance with a study by Wong et al that suggested that end-of-life care among elderly dialysis patients may be driven by practice patterns rather than patient preferences. It is understandable that practice patterns may be heavily influenced by the healthcare system and institutional policies, which reflects in this study as differences across the two countries.
Although the awareness of palliative care needs in our patient population is growing, a higher system-level change may be needed before we see a significant change in the culture and subsequent incorporation of renal palliative medicine in routine nephrology care. This study offers us an opportunity to reflect on our own practice and identify the barriers that prevent us from identifying and meeting our patients’ needs. The end-of-life dialysis conversation is always difficult, but the discussion still needs to happen.
We may have a long way to go, but we have certainly taken the first steps by realizing our shortcomings…
– Post prepared by Ritu Soni, AJKDBlog Contributor.