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

Abstract

Palliative or conservative, non-dialytic care is increasingly seen as an option to dialysis, especially in elderly chronic kidney disease (CKD) patients with multiple comorbidities and a poor prognosis. This therapeutic option should be discussed along with dialysis options with all patients being educated about renal replacement therapies. Because the symptom burden of CKD is high, all CKD patients can potentially benefit from palliative care once CKD is diagnosed; palliative care 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 do-not-resuscitate choices and Physician Orders for Life-Sustaining Treatment (POLST) where available should be completed by all CKD patients. Some discussion of prognosis is required in order for patients and families to complete such directives, and 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 conservative care as well as those who withdraw from dialysis.