Given that palliative care can be pursued while an individual is receiving curative care, should its potential benefits be considered more often? Should palliative care be considered earlier for very ill patients who are hospitalized and have acute kidney injury? A recent study in CJASN found that 46% of these patients died while in the hospital.
“[These] patients with AKI were seriously ill and had a high mortality rate, but what was not expected was that palliative care was often called later in the hospital course than for those without AKI despite having such a high mortality,” explains Jennifer S. Scherer, MD, a nephrologist at NYU Grossman School of Medicine. “There are several clinical explanations for this, however given the high mortality it does suggest that patients and families could have benefited from earlier support from palliative care.”
The observational study, Utilization of Palliative Care for Patients with COVID-19 and Acute Kidney Injury during a COVID-19 Surge, involved an analysis of data from three acute care hospitals located in Manhattan, Brooklyn, and Long Island. Specifically, the research concerned 4,276 patients with COVID-19 and 1,310 patients from this population (31%) who developed AKI. Compared with those without AKI, a higher proportion of those with AKI died during hospitalization (46% vs. 5%) or were discharged to inpatient hospice (6% vs. 3%), while a lower proportion were discharged home (24% vs. 77%). Despite greater use of palliative care, patients with AKI had a significantly longer length of hospital stay, more intensive care unit admissions, and more use of mechanical ventilation.
“There has historically been low use of palliative care for those with acute kidney injury,” recognizes Scherer in a podcast about the study. “The late consultation of palliative care in a patient population with high mortality suggests a missed opportunity to provide emotional support to families who are likely struggling over caring and supporting a loved one with an acute serious illness especially during a time with restrictive visitation policies.”
The study also found that palliative care consults occurred later for those who started on kidney replacement therapy (KRT) compared with those who were not (12 days from admission vs. 9 days); 66% of patients with AKI who initiated KRT such as dialysis received palliative care vs. 37% of those with AKI who did not receive KRT.
“The nephrology community can benefit from further study of the impact of palliative care for those with acute kidney injury as well as expiration of timing of palliative care consultations for these patients,” Scherer adds.
P.T. Conway and E.V. Hickey III, who wrote COVID-19 and Palliative Care: Observations, Extrapolations, and Cautions, an accompanying Patient Voice, point out that the study is not sufficient to support “system-wide changes that could interfere with the perceived viability of kidney patients, including AKI patients, and expected care norms during a medical crisis.”
“As members of the national patient and policy leadership team for the American Association of Kidney Patients, we offer strong caution against the generalization or extrapolation of this research, which lacks quantitative or qualitative patient insight data and patient and family perceptions of palliative care,” they emphasize.