Can I stop dialysis?” asked my 88-year-old wheelchair-bound patient on a late fall afternoon. I squinted my eyes to block not only the streaming sunlight but my reaction: one of bewilderment.
In a 2015 study of nephrology fellows, 99% of respondents agreed that physicians have a responsibility to help patients at the end of life (EOL) and in preparing for death; however, in their fellowship training, less than one-half were taught how to respond to a patient’s request to discontinue dialysis therapy, conduct a family meeting about dialysis options, or determine when to refer patients to hospice or palliative care
Offering patients life-prolonging treatments while at the same time improving their quality of life is a balancing act. With time, we learn that more care is not necessarily good care, that not every test or treatment available to the patient is needed, and that, at times, they may cause more harm than good.
A clinician must judge which treatment is quantitatively futile (it simply cannot physiologically work) or inappropriate. The latter is a gray zone and at times takes into consideration the clinicians’, patients’, and surrogates’ personal conceptions about life and treatment goals. One such treatment is dialysis in a
Psychologic concerns are prominent in chronic illness, such as ESRD, in which patients face significant morbidity, mortality, and complex treatment decisions. However, these symptoms are often not recognized or effectively treated. Because rates of depression and anxiety increase in this population, there is a need for interdisciplinary team collaboration among nephrology, palliative care, and mental health. Here, we present a guide tailored to the kidney care team for identifying and managing depressive and anxious symptoms in ESRD patients.
One in five patients with ESRD is diagnosed with depression, which is higher than in kidney transplant patients (1
Effective communication is necessary when providing medical care but can prove challenging when attempting to match patients’ values to therapies. Nephrologists often participate in difficult conversations with patients and their families, most commonly involving dialysis in patients with chronic kidney disease (CKD) and ESRD. Despite this, most nephrologists and nephrology fellows do not feel prepared for these difficult conversations (1–3).
In recent years, there has been an increasing focus on goals of care and utilization of a palliative approach in advanced CKD and dialysis care. The aim is to address the symptoms, pain, and stress of
A foremost goal of American medicine for the 21st century to improve the quality of health care is individualized, patient-centered care. The recommended means to achieve this care is shared decision-making, a conversation process in which the physician communicates information to the patient about diagnosis, prognosis, and treatment options and the patient communicates to the physician about his or her history, values, and treatment preferences. Together, the two share responsibility in reaching a common understanding of the patient’s preferred treatment course. This process has been called “the pinnacle of patient-centered care” (1).
In this issue, Kidney News Editorial Board member Edgar Lerma, MD, interviewed Christian T. Sinclair, MD, this month’s special section editor, about palliative care in kidney disease. Dr. Sinclair is Assistant Professor in the Division of Palliative Medicine at the University of Kansas Health System in Kansas City, KS. We hope you enjoy this introduction to palliative care in nephrology, as well as the set of articles that follow. More articles will appear in the next issue.
Conservative care in ESRD seems to be in the limelight of late. However, this is not a
Patients with ESRD experience a high degree of symptom burden—physical symptom burden akin to patients with advanced cancer, along with emotional and spiritual suffering. In addition, ESRD patients on maintenance dialysis have the highest levels of medicalization at the end of life, surpassing what is experienced by their counterparts with other advanced chronic illnesses (1). Although high-intensity health care at the end of life may be goal concordant for a minority of patients, it is not on a population level. A large Veterans Affairs study evaluated family-reported quality of end-of-life care among 57,753 decedents and noted that quality
Patient-reported outcomes in patients with chronic kidney disease (CKD)/ESRD have assumed increasing importance during recent years, because these factors also play a vital role in affecting outcomes, as do traditional survival determinants. A comprehensive understanding of measurements coming directly from patients is expected to assist physicians in improving patient care and facilitate patients in optimizing their decision-making processes. Incorporating patients’ viewpoints and ameliorating their discomfort throughout the course of CKD and even the dialysis career constitute an important aim for optimal supportive care for renal patients. Furthermore, when CKD patients are required to choose between the option of dialysis or
We cannot discuss too much or focus in too much detail on the issues when it comes to the historic transition of power and influence post-election. Much has been said about radically changing the government, and health care has been in the crosshairs throughout the election and in planning for transition. Governance and policy will be all important in 2017. Although there is limited detailed conversation about how change will occur, there surely will be new policy and rules.
The clearest promise has been that the Affordable Care Act (ACA) would be dismantled and fully repealed. Soon after the election,
The likely repeal of the Affordable Care Act (ACA) early in the Trump administration has placed patients who gained coverage through the legislation and the ACA’s value-based kidney care initiatives in limbo.
The Trump administration and Republican leaders in Congress are vowing to quickly repeal the ACA when they take power in January 2017. The repeal is expected to allow a 2–3 year grace period for parts of the ACA to continue. After that time, Republicans are expected to replace the ACA with their own legislation.
The planned repeal raises many questions about what will happen to patients who gained