Conservative/Palliative Treatment and End-of-Life Care in Chronic Kidney Disease

Abstract

There is an urgent unmet need for kidney supportive care services for patients with chronic kidney disease (CKD). Many have a high symptom burden that impairs their quality of life, multiple comorbid conditions, a shortened life expectancy, and significant cognitive and functional impairments. Kidney supportive care refers to primary palliative care provided directly by the kidney care team and includes the skills that ideally all providers should have: management of uncomplicated pain and symptoms including anxiety and depression, and essential discussions about prognosis, goals of treatment, code status, quality of life, and suffering. Palliative care usually indicates care provided by a subspecialty-level team that partners with the kidney clinicians to address more complicated symptoms and challenging communication or decisions. Because older patients with chronic kidney disease often have multiple comorbidities and a poor prognosis even with dialysis treatment, active medical management without dialysis (also known as conservative kidney management) is increasingly seen as an acceptable alternative to dialysis for these patients. This therapeutic option should be discussed along with dialysis options with all patients being educated about kidney replacement therapies. All CKD patients can potentially benefit from kidney supportive care; it is appropriate not only at the end of life but also throughout the course of CKD. Advance care planning can identify patient and family goals and thereby direct appropriate treatments. The illness trajectory of CKD typically offers multiple opportunities for nephrologists to initiate advance care planning discussions with patients and families. Advance directives like naming a health-care surrogate for decision-making and medical orders like do-not-resuscitate and Portable Orders for Life-Sustaining Treatment (POLST) where available should be completed by all CKD patients who desire treatment limitations at the end of life. Some discussion of prognosis is required in order for patients and families to complete advance directives and medical orders. It is the nephrologist’s role to initiate these conversations. End-of-life care is best delivered by an interdisciplinary team of providers focusing on the physical, psychological, and spiritual aspects of suffering and providing bereavement care to loved ones. Hospice is an example of such care and may benefit CKD patients choosing active medical management without dialysis as well as those who withdraw from dialysis.