Incorporating Supportive Care in Nephrology Research, Training, and Care

Palliative care’s value and intrinsic relevance to CKD care are now increasingly recognized, and nephrologists are embracing the challenges of incorporating palliative care into their research, training, and care delivery agendas. We still have a long way to go, but we anticipate a new age in clinical nephrology as we determine how best to address these issues.

Among ASN’s contributions to the American Board of Internal Medicine’s “Choosing Wisely” campaign (Five Things Physicians and Patients Should Question) was the statement: “Don’t initiate chronic dialysis without ensuring a shared decision-making process between patients, their families, and their physicians.” (1).

In short, advance care planning is needed in order to identify a patient’s values and goals. Informed and shared decision-making about starting dialysis can be achieved only when the benefits and harms of dialysis are provided within the context of expected prognosis.

ASN’s Choosing Wisely statement illuminates the importance of palliative care in the overall management of CKD. The statement continues: “Limited observational data suggest that survival may not differ substantially for older adults with a high burden of comorbidity who initiate chronic dialysis versus those managed conservatively” (1). Conservative management (palliative care and no dialysis) may be especially appropriate for elderly chronic kidney disease (CKD) patients with high comorbidity.

Palliative care is part of chronic disease management throughout a patient’s illness and not only near the end of life. Shared decision-making, discussing prognosis, and advance care planning, along with symptom assessment and treatment, end-of-life care, and bereavement support are all aspects of palliative care in which nephrologists will increasingly engage within the realm of CKD management.

Despite the growing appreciation for the importance of palliative care, however, nephrologists are poorly prepared to participate in these aspects of CKD care. A 2003 survey of second year nephrology fellows showed that although most thought palliative care was an important part of nephrology, few felt they received training to assist them in the provision of such care (2). Ten years later, despite tremendous growth in the literature on renal palliative care and the publication of clinical practice guidelines addressing supportive care of CKD patients (3), nephrology fellows remain unprepared and poorly trained to deliver such care (4,5).

Recognizing the importance of palliative care to nephrologists, Kidney Disease: Improving Global Outcomes (KIDGO) has formed a workgroup to synthesize the literature around issues of of palliative care, including advance care planning. The workgroup will also look at prognostication; symptom assessment and management; initiating, withholding, and withdrawing dialysis; and conservative care in developed and developing countries. The ultimate aim is to develop clinical practice guidelines that will help integrate palliative care into renal care globally.

Stay tuned as the KDIGO guidelines unfold and palliative care gains increasing attention among those involved in kidney care.

Notes

[1] Jean L Holley, MD, is affiliated with the University of Illinois, Urbana-Champaign, and with Carle Physician Group, and Sara N. Davison, MD, is affiliated with the University of Alberta and is Workgroup Chair for the KIDGO Palliative Care Initiative.

References

1. www.choosingwisely.org accessed November 24, 2013.

2. Holley JL, et al. The need for end-of-life training in nephrology: National survey results of nephrology fellows. Am J Kidney Dis 2003; 42:813–820.

3. Renal Physicians Association. SharedDecision-Making in the Appropriate Initiationof and Withdrawal from Dialysis. Clinical Practice Guideline (ed 2). 2010:Rockville, MD.

4. Shah HH, et al. Palliative care experience of US adult nephrology fellows: a national survey. Ren Fail Sept 2013 epub ahead of print PMID 24059838

5. Combs SA, et al. Palliative care training during fellowship: National survey of second year nephrology fellows. Presented at American Society of Nephrology Annual Meeting, Atlanta, Nov 2013.

January 2014 (Vol. 6, Number 1)