#NephMadness 2020: Koncicki’s Pick for the Ethics Region – Dialysis for Patients at the End-of-Life

Holly Koncicki @HollyMarieMD

Holly Koncicki completed her medicine residency training at Mount Sinai Hospital, followed by completion of an integrated fellowship in nephrology and palliative medicine. She is currently appointed as Assistant Professor at the Icahn School of Medicine at Mount Sinai. Dr. Koncicki is working closely with the fellowship leadership at Mount Sinai in shaping the curriculum for the integrated nephrology and palliative care fellowship.

Competitors for the Ethics Region:

Policy-Driven Outcomes for Dialysis vs Patient-Driven Choice for Dialysis

End-of-Life Care for Patients on Dialysis vs Dialysis for Patients at End-of-Life

The “Dialysis for Patients at the End of Life” team has the potential to provide quite the upset in this year’s NephMadness tournament. No one is expecting this quiet team to go all the way. Who is this team? Let’s take a closer look. 

It’s a team filled with dreamers. They have a unique skill set, communication, which many of them may have learned at a training camp called “Nephro-Talk”. Though anyone can learn this essential skill, many have not due to lack of standardized education during fellowship.  This team is ready to talk about what few nephrologists will: prognosis. 

Here’s what they know: The growth of maintenance dialysis patients over the age of 75 has doubled in recent years. Adjusted mortality for patients on dialysis is nearly twice that of cancer and more than twice that of patients with heart failure or stroke. Five-year survival of patients on hemodialysis is estimated to be about 42%. A recent study of 400 incident dialysis patients over the age of 65 estimated 1-year mortality to be 54.5%. 

Patients want to know about prognosis, and the discrepancy between what patients think their prognosis is and what it actually is, is staggering. In one study, patients on dialysis were asked how long they thought people with similar health conditions to them live. Over half who answered reported an expected survival of > 10 years, whereas actual survival was anticipated to be < 5 years. This suggests that, though starting dialysis, many people are at high risk of poor outcomes including limited survival.

There is a theoretical option of continuing dialysis while on hospice for patients with a prognosis of less than 6 months and a terminal diagnosis unrelated to their ESKD, though logistically this is not always feasible. What about patients at the end-of-life, who don’t have another diagnosis to enroll under, or who have longer than 6 months but still a limited survival, and wish to continue dialysis? These patients are otherwise forced to discontinue dialysis treatments prior to receiving hospice care. 

In terms of what our patients value, increased survival is actually not at the top of their list – other metrics such as independence take the top pick. Here is the big question: Is there another way to deliver dialysis at the end-of-life? And should dialysis treatments differ for patients with an expected prognosis of a year or less? This team thinks so.  

Not many other teams can compare to their talent of eliciting patient goals and preferences, and this is where the team may run away with the game. Here’s their strategy: First, they discuss prognosis and goals of care. This is a time-consuming process but the reward is tremendous. Eliciting what is most important to the patient will help the provider make recommendations on how to align patient-centered metrics with their dialysis treatments, rather than focusing on standard dialysis care metrics. 

Then this team really pulls out a playbook that many have never seen before. As they try to focus on patient-centered metrics, such as symptom management and health-related quality-of-life, they may do things like accepting a central venous catheter in lieu of pursuing an AVG or AVF in the patient (stunned silence from the crowd). They may liberalize a patient’s diet, permitting hyperphosphatemia and limit medications to allow for hyperparathyroidism (crowd gasps!). They may focus more on optimization of volume status and with that, they may decrease treatments to just twice per week, accepting lower clearances (opposing coach throws hands up in the air). 

What is amazing is that this team is able to pull off such a refined skill set, especially since playing the way they play, they are at risk of losing reimbursement. Yup, that’s a big barrier, and though this strategy is so important for patient care, other teams are hesitant to follow them as CMS payments are not based on these patient-centered metrics. Like I said, this team is filled with dreamers…they think that it is time that things change. Maybe if they take the win in this tournament, people will start paying attention and asking the hard questions to get more teams to follow their lead. 

– Guest Post written by Holly Koncicki @HollyMarieMD

 

As with all content on the AJKD Blog, the opinions expressed are those of the author of each post, and are not necessarily shared or endorsed by the AJKD Blog, AJKD, the National Kidney Foundation, Elsevier, or any other entity unless explicitly stated.

 

Submit your picks! | #NephMadness | @NephMadness | #EthicsRegion

 

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