renal supportive care – “setting the scene” kelly li, nephrologist and palliative medicine...
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Renal Supportive Care – “Setting the scene”
Kelly Li,Nephrologist and Palliative Medicine
Trainee
Frank Brennan Palliative Care Consultant,
Department of Nephrology St George Hospital
Sydney
Renal Supportive Care Master Class,
Sydney, August 2015
• The nature of Nephrology
• The nature of Palliative Care
• What possible interface exists between the two disciplines ?
• The scope of Renal Supportive Care
• An overview of the Master Class
A tale of two specialties
The scope and responsibility of the discipline of Nephrology
What nephrologists do...
• When I first entered nephrology:
• BP <140/90
• ACEI reduces mortality
• As many transplants as possible
Whilst that hasn’t changed...
Growing number of elderly dialysis patients– Not best transplant candidates
ANZDATA registry 37th annual report
• Growing number of elderly dialysis patients– Not best transplant candidates– Lots of comorbidities
ANZDATA registry 37th annual report
The hardest question for nephrologists
Will my patient benefit from dialysis?
The hardest question for nephrologists
• Will my patient benefit from dialysis?
• https://s-media-cache-ak0.pinimg.com/236x/99/f8/37/99f837218df3b146a2bf05314936735d.jpghttps://s-media-cache-ak0.pinimg.com/236x/99/f8/37/99f837218df3b146a2bf05314936735d.jpg
Dialysis is life-saving for some
• http://www.china.org.cn/china/2013-01/21/content_27747038.htm
Newer and better machines
• http://health.clevelandclinic.org/wp-content/tn3/0/artifical-kidney-dialysis.jpg
• https://www.fresenius.com/images/Dialysis_machine.jpg
But is dialysis for everyone with ESKD?
But is dialysis for everyone with ESKD?
Limited or no benefit for some?
Murtagh F et al. Dialysis or not? A comparative survival study of patients over 75 years with chronic kidney disease stage 5. NDT (2007) 22: 1955–1962
Dialysis in Frail Elders — A Role for Palliative CareRobert M. Arnold, M.D., and Mark L. Zeidel, M.D.
Next
Volume 361:1597-1598
October 15, 2009
Kurella et al. Functional status of elderly adults before and after initiation of dialysis. NEJM 2009;361:1539–47
Does everyone who has ESKD commence dialysis ?
In Australia, for every one patient with ESKD receiving Renal Replacement Therapy (RRT)
there is another who does not receive RRT
Australian Institute of Health and Welfare Research, 2011
For those who don’t go on dialysis
• How do we look after these patients?
– Can we still help?
– What are the care needs?
– What supports are there?
“What will happen to me if I don’t start Dialysis ?”
CKD conservative management
CKD conservative management
NOT abandonment
CKD conservative management
NOT discharge to Palliative Care
If this is being raised as an option :
What does a Conservative pathway mean ?
What is its content ?
Can we make predictions about theircourse ?
Challenge is
to ensure that this pathway of management is not seen as “second best” or inadequate
but is thorough, systematic and evidenced-based
CKD conservative management
• Fluid/BP/electrolyte/anaemia
• Symptom management
• Psychosocial support
• Advance care planning
• Community palliative care
• Terminal phase
Withdrawal from dialysis
Survival on dialysis
ANZDATA registry 37th annual report
ANZDATA registry 37th annual report
ANZDATA registry 37th annual report
End of life discussions
• Communication skills
• Time
• Preparedness
• Willingness
The quality of dying
The circumstances in which patients with ESRD die varies considerably
If it is an expected death (eg. after the cessation of dialysis) the management of the dying phase is crucial
and the manner of that dying will be remembered forever by the family
Symptom control
Nephrology clinic Nephrologist says...
• Fluid restriction• Sodium restriction • Potassium
restriction• Phosphate
restriction• Caloric restriction• Sugar restriction
(diabetics)
Nephrology clinic Nephrologist says...
• Fluid restriction• Sodium restriction • Potassium
restriction• Phosphate
restriction• Caloric restriction• Sugar restriction
(diabetics)
Renal patient says...
https://s-media-cache-ak0.pinimg.com/236x/9a/58/e1/9a58e14e0e454d25670eb91254051381.jpg
“Patients with CKD, particularly those with ESRD are among the most symptomatic of any chronic disease group.”
Murtagh F, Weisbord S. Symptoms in renal disease. In Chambers EJ et al (eds) Supportive Care for the Renal
Patient 2010, 2nd ed, OUP.
The dialysis unitNephrology assessment
• Blood pressure• Fluid status• Haemoglobin• Potassium• Calcium/phosphate• Vascular access• Nutrition• Cardiovascular/
metabolic
The dialysis unit
Palliative care assessment
• RUG ADL
• Problem severity scare– Pain– Other symptoms– Psychological/spiritual– Family/carer
• Patient rated score– Difficulty sleeping– Appetite problems– Nausea– Bowel problems– Breathing problems– Fatigue– Pain – Uraemic pruritus– Restless legs
Saini et al. Comparative pilot study of symptoms and quality of life in cancer patients and patients with end stage renal disease. Palliative Medicine 2006; 20: 631-636
Saini et al. Comparative pilot study of symptoms and quality of life in cancer patients and patients with end stage renal disease. Palliative Medicine 2006; 20: 631-636
Do nephrology and palliative care
have anything in common?
Nephrologists can be a little eccentric
The world of palliative medicine is much more civilised...
What is Palliative Care ?
WHO definition (2002)WHO definition (2002)
Palliative Care is an approach which improves the quality of life of patients and their families facing life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.
Modern view of Palliative Medicine
A. That Palliative Care is involved in all patients with life-limiting illnesses – not just cancer patients.
Modern view of Palliative Medicine
B. Early involvement : “There is wide recognition that the principles of palliative care should be applied as early as possible in the course of any chronic, ultimately fatal illness.”
C. The concept of concurrent care : that active care and palliative care can and should occur concurrently.
D. That the “death –bed consultation” is a set of missed opportunities.
Benefits of early involvement–
- reinforcement of idea of comfort.
- that symptom control is impeccable
throughout.
- establishing a rapport/trust
- demystifying analgesia (opioids)
- introducing idea of Community Palliative Care
- helps avoid sense of abandonment
Barriers to effective Palliative Care
Belief that Palliative Care is simply terminal care… “not now, he’s not ready for it”
“It will send the wrong message to her”
“It will just take away her hope.”
Why is Palliative care/ a palliative approach relevant to patients with ESKD ?
1. Epidemiology
2. Mortality
ESRD patients
Overall patients with ESKD
with or without RRT have a
reduced life expectancy
compared to age-matched controls.
DIALYSIS
For patients on dialysis 13 % die each
year (ANZDATA Report 2014)
For those aged 75 years and older that figure is 25 %
3. Symptomatology
4. Quality of life
QOL - St George dialysis (SF-36 Scores)
0102030405060708090
100
PF RP BP GH VT SF RE MH
Mea
n sc
ore
(max
100
)
2001
2003
2004
2006
2008
Aust Norms
Overall QoL is very resistant to significant change.
5. The quality of dying
Competencies
Realistically, given issues of manpower,
it may not be possible for a Palliative Care health professional to be present in every
Renal Unit
What are the core competencies in a “palliative approach” to patients with ESKD for Nephrologists ?
4 Pillars of a Palliative approach
• Communication
• Symptom management
• Psychosocial support
• Care of the dying patient
Renal Supportive Care – a brief history
USA
In 1998 -
The Baystate Renal-Palliative Care Intitiative
Clinical Practice Guidelines on Shared Decision-Making in the Appropriate Initiation of and Withdrawal from Dialysis
Renal Physicians Association of the USA and
the American Society of Nephrology. 2000.
www.renalmd.org
In 2002 –
RPA/ASN Position Paper on Quality Care at the End of Life
In 2004 –
Renal-Palliative Care Curriculum for Nephrology Trainees
Moss AH, Holley JJ. Core Curriculum in Nephrology : Palliative Care. Am J Kid D 2004;43:172-185.
In 2010 –
Clinical Practice Guidelines on Shared Decision-Making in the Appropriate Initiation of and Withdrawal from Dialysis
Renal Physicians Association of the USA 2010.
United Kingdom
Annual Symposia on Renal-Palliative Care co-organised by both disciplines
National Service Framework for Renal Services Part 2 (UK) - 2005
Concentrated on the care of Dialysis patients nearing the end of life
Royal College of Physicians (UK)
The Changing Face of Renal Medicine in the United Kingdom
2007
National Framework for the Implementation of End of Life Care in Advanced Kidney Disease
2009
Australia and New Zealand
Throughout Australia and New Zealand there are a small but growing number of Renal Supportive Care services being formed or considered.
Crail S, Brown M et al.
ANZSN Australasian Renal Supportive Care Position Paper and Guidelines
Nephrology 2013;18: 401-454
Formation of a state-wide service in NSW
Internationally
KDIGO Controversies Conference on Supportive Care in CKD.
Mexico City 2013
Davison SN et al.
Executive summary of the KDIGO Controversies Conference on Supportive Care in CKD : developing a roadmap to improving quality care.
Kidney International, Advance online publication, April 29 2015.
Textbooks
Chambers EJ, Germain M, Brown E (eds)
Supportive Care for the Renal Patient
2nd edition, 2010
Oxford University Press
Brown E, Chambers EJ, Eggeling C.
End of Life Care in Nephrology
-from Advanced Disease to Bereavement
2007
Oxford Specialist Handbooks
First Australian and New Zealand
Renal Supportive Care Master Class
Sydney, August 2015
The issues in decision making for patients with ESKD in the commencement of either dialysis or a conservative, non dialytic pathway.
Dr Celine Foote, Nephrologist
Symptom management in Chronic Kidney Disease – Part 1
Frank Brennan, Palliative Care Physician
Symptom management in Chronic Kidney Disease – Part 2
Anxiety and Depression
Dr Kirsty Morris, Consultant Psychiatrist
Advance Care Planning in Nephrology
Dr Elizabeth Stallworthy, Nephrologist
Renal Supportive Care – Indigenous issues.
Dr Cherian Siv, Nephrologist
Canvassing difficult clinical situations
Small group discussions co-facilitated by a Nephrologist and Palliative Care Physician.
The care of the dying patient who has ESKD
Dr Kat Urban, Palliative Care Physician
Conclusion
The histories of the two disciplines are intersecting
Conclusion
A mutual acknowledgement of need-
The role of Palliative Care in ESRD
The last decade has seen considerable levels of advocacy, attitudinal shift, research, publications and collaboration
Throughout the course of the illness there are times when difficult conversations may need to occur
Palliative Care/ a palliative approach can play an important role throughout the course of ESRD
4 Pillars of a Palliative approach
• Communication
• Symptom management
• Psychosocial support
• Care of the dying patient
Applies to patients who are being managed with either with RRT or conservatively