Mapping the future: Implementation strategies for kidney supportive care

With the recent finding that late referral to hospice for patients on dialysis does not reduce hospitalization, ICU admission or Medicare costs compared to patients on dialysis who died without hospice, 1 the evidence continues to accumulate that end-of-life care for patients on dialysis substantially lags behind that for patients with cancer, dementia and heart failure. 2,3 Alvin H. Moss Compared to patients with other chronic diseases, studies have shown patients on dialysis have a high (80%) hospitalization rate in the last 3 months of life,4 are more likely to be admitted to an ICU and undergo an intensive procedure such as cardiopulmonary resuscitation, feeding tube insertion or mechanical ventilation in the last month of life and die in the hospital. 2 Paradoxically, patients on dialysis have been recognized as being especially appropriate for supportive care, including end-of-life care interventions, because of their high comorbidity, shortened life expectancy, high symptom burden and dependence on a long-term life-sustaining treatment for their survival. 5

Nephrologists and other clinicians involved in kidney care cannot depend on supportive care specialists to deal with these substantial unmet end-of-life care needs in their patients. In 2010, a task force of the American Academy of Hospice and Palliative Medicine estimated an acute physician shortage of 2,500 to 7,500 specialty palliative medicine physicians in the U.S. and there is an insufficient number of physicians in palliative medicine fellowship programs to meet this shortage in the future. 6 In addition, few advanced patients with chronic kidney disease on dialysis receive supportive care consultations when they are hospitalized. When it has been provided, supportive care has been associated with shorter hospital stays and lower costs for patients with ESRD who died in the hospital, along with higher hospice referral and decreased 30-day readmission for patients with ESRD discharged alive. 7 Due to this shortage, it is incumbent on nephrology clinicians to learn primary supportive care skills. These include basic management of pain and symptoms, basic management of depression and anxiety and basic discussions with patients about prognosis, goals of treatment and values and preferences for end-of-life treatment. 8 Surveys of nephrology fellows have indicated they believe it is their responsibility to provide end-of-life care to patients on dialysis and it is important to learn how to do so. However, it is not being taught in most nephrology fellowship programs. 9 A promising sign is that much energy and innovation is presently being devoted to improving the communication skills of nephrology fellows in programs like NephoTalk. 10


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