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      End-of-Life Care for Patients Afflicted with Incurable Malignancy and End-Stage Renal Disease


      Indian Journal of Palliative Care

      Medknow Publications & Media Pvt Ltd

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          End-stage renal failure (ESRD) patients (even without associated malignancy) have a high mortality and morbidity. As per the US Renal Data System (USRDS), the annual crude mortality is approx 20%.[1] The added presence of incurable malignancy definitely worsens the clinical outcomes in terms of quality of life, morbidity and mortality. Hence the utility (or otherwise) of initiating/continuing dialysis must always be assessed in a holistic manner.[2] However, currently most nephrologists are not comfortable with the idea of either withholding or withdrawing dialysis in these clinical settings. A recent study amongst US nephrology fellows revealed that more than two-thirds of the respondents thought that a formal rotation in palliative care during fellowship would be useful.[3] It is in this context that the article by Jing et al. in the current issue of the Journal throws light on management of patients afflicted with incurable malignancy and ESRD requiring dialysis support therapy.[4] As highlighted by the authors these patients have multiple co-morbidities with poor nutrition accompanied by anxiety and depression. The prevalence of such cases in the population is on the rise. Not addressing the need of palliative care in these patients may in fact subsequently lead to tribulation for the patient and the family.[5] The primary goal of palliative care is alleviation of suffering and improving the quality of life of both the patients and their families. Management of renal failure by peritoneal dialysis (PD), which can be conveniently performed both at home and in the hospice setting, is thus of great help. Delivering the usual optimal dialysis dose in these patients would have limited clinical benefits. Rather, the patient would benefit from the treatment of the various associated symptoms. One of the problems of renal failure is fluid overload which can lead to distressing dyspnea and/or orthopnea. This can be treated/prevented with fluid restriction, diuretics and PD with exchanges of hypertonic glucose solution. Even in cases where PD has been withdrawn, intermittent PD exchanges can easily be done when required to remove extra fluid for the relief of the patient. The other frequent problem in such patients is chronic pain. This can be treated with the various available medications (including opioids) with appropriate dosage adjustment for renal failure. Other symptoms like nausea, pruritus, etc., can also be treated with drugs. Sedatives may also be used as necessary. Unnecessary use of dialysis only increases the cost of health care without accrual of significant benefits to the patients, their families or the society as a whole. Hence universal screening of all ESRD patients for palliative care needs has now been proposed.[6] The time has come for nephrology teams to work in tandem with palliative care practitioners for the care of these patients.[7 8]

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          Should there be an expanded role for palliative care in end-stage renal disease?

          In this review, we outline the rationale for expanding the role of palliative care in end-stage renal disease (ESRD), describe the components of a palliative care model, and identify potential barriers in implementation. Patients receiving chronic dialysis have reduced life expectancy and high rates of chronic pain, depression, cognitive impairment, and physical disability. Delivery of prognostic information and advance care planning are desired by patients, but occur infrequently. Furthermore, although hospice care is associated with improved symptom control and lower healthcare costs at the end of life, it is underutilized by the ESRD population, even among patients who withdraw from dialysis. A palliative care model incorporating communication of prognosis, advance care planning, symptom assessment and management, and timely hospice referral may improve quality of life and quality of dying. Resources and clinical practice guidelines are available to assist practitioners with incorporating palliative care into ESRD management. There is a large unmet need to alleviate the physical, psychosocial, and existential suffering of patients with ESRD. More fully integrating palliative care into ESRD management by improving end-of-life care training, eliminating structural and financial barriers to hospice use, and identifying optimal methods to deliver palliative care are necessary if we are to successfully address the needs of an aging ESRD population.
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            Five policies to promote palliative care for patients with ESRD.

            Patients with ESRD experience complex and costly care that does not always meet their needs. Palliative care, which focuses on improving quality of life and relieving suffering for patients with serious illnesses, could address a large unmet need among patients with ESRD. Strengthening palliative care is a top policy priority for health reform efforts based on strong evidence that palliative care improves value. This commentary outlines palliative care policies for patients with ESRD and is directed at policymakers, dialysis providers, nephrology professional societies, accreditation organizations, and funding agencies who play a key role in the delivery and determination of quality of ESRD care. Herein we suggest policies to promote palliative care for patients with ESRD by addressing key barriers, including the lack of access to palliative care, lack of capacity to deliver palliative care, and a limited evidence base. We also provide examples of how these policies could be implemented within the existing ESRD care infrastructure.
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              Palliative care experience of US adult nephrology fellows: a national survey.

              Palliative care (PC) training and experience of United States (US) adult nephrology fellows was not known. It was also not clear whether nephrology fellows in the US undergo formal training in PC medicine during fellowship. To gain a better understanding of the clinical training and experience of US adult nephrology fellows in PC medicine, we conducted a national survey in March 2012. An anonymous on-line survey was sent to US adult nephrology fellows via nephrology fellowship training program directors. Fellows were asked several PC medicine experience and training questions. A total of 105 US adult nephrology fellows responded to our survey (11% response rate). Majority of the respondents (94%) were from university-based fellowship programs. Over two-thirds (72%) of the fellows had no formal PC medicine rotation during their medical school. Half (53%) of the respondents had no formal PC elective experience during residency. Although nearly 90% of the fellows had a division or department of PC medicine at their institution, only 46.9% had formal didactic PC medicine experience. Over 80% of the respondent's program did not offer formal clinical training or rotation in PC medicine during fellowship. While 90% of the responding fellows felt most comfortable with either writing dialysis orders in the chronic outpatient unit, seeing an ICU consult or writing continuous dialysis orders in the ICU, only 35% of them felt most comfortable "not offering" dialysis to a patient in the ICU with multi-organ failure. Nearly one out of five fellows surveyed felt obligated to offer dialysis to every patient regardless of benefit. Over two-thirds (67%) of the respondents thought that a formal rotation in PC medicine during fellowship would be helpful to them. To enhance clinical competency and confidence in PC medicine, a formal PC rotation during fellowship should be highly considered by nephrology training community.

                Author and article information

                Indian J Palliat Care
                Indian J Palliat Care
                Indian Journal of Palliative Care
                Medknow Publications & Media Pvt Ltd (India )
                May-Aug 2014
                : 20
                : 2
                : 99-100
                Department of Nephrology, All India Institute of Medical Sciences, New Delhi, India
                Author notes
                Address for correspondence: Dr. Dipankar Bhowmik; E-mail: dmbhowmik@
                Copyright: © Indian Journal of Palliative Care

                This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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