Nephrology Hypertension

Hemodialysis: Withdrawing from Dialysis and the Role of Palliative Care

Does this patient have a poor prognosis?

Answer the "Surprise Question":

"Would you be surprised if the patient dies within the next 6 months?

Generally these will be patients over 75 years of age with at least one comorbidity.

What tests to perform?

  • The simplest test is to answer the "Surprise Question."

  • A more accurate mortality tool is found at http://touchcalc.com/calculators/sq (this is also available as an smart phone app Qx Calculate)

  • Simple scoring tools were published by Couchoud (2008) and Mauri (2008).

  • If the answer to the Surprise Question in "no" you would not be surprised, and/or the predicted mortality is < 6 months you should consider withdrawal of dialysis or withholding dialysis if the patient has not started yet. This should be accompanied by "Supportive" or Palliative care.

How should patients with a poor prognosis be managed?

  • Discuss prognosis in a sensitive and compassionate way with the patient and family. The following communication techniques are helpful in breaking bad news: SPIKES and NURSE. Remember that the patient’s support system (e.g., family and friends) also likely need support from the healthcare team when having these difficult discussions.

  • Get help from palliative care and geriatric consultants and refer to hospice

  • Have patient complete Advanced Care Plan such as "Five Wishes" and "Caring Conversations"

  • In the United States those states that have The Physicians Orders for Life Sustaining Treatment Paradigm (POLST), complete the POLST with the patient and family.

  • Discontinue treatments that do not contribute to patient comfort; non comfort meds, IVs, tube feedings.

  • Treat troublesome symptoms including insomnia, restless legs and pruritus and consider non-pharmacologic approaches before using medications. For pain, use renal appropriate meds and doses to avoid neurotoxicity (i.e., no Demerol)

What happens to patients with a poor prognosis?

  • Patients who stop dialysis with little residual renal function die within 8 days median time period. If a patient has is stage 5 chronic kidney disease (CKD) and has not started dialysis they may never become uremic and may live months or years.

    • Patients aged 75 or older have a very slow progression of CKD and are much more likely to die rather than reach end-stage renal disease (ESRD) (dialysis). Early start to dialysis has not been shown to be beneficial.

    • Recent data has shown that patients aged ≥ 80 who receive “conservative management” (e.g., no dialysis) have no difference in survival compared to those who choose dialysis. The survival advantage for patients ≥ 70 with significant comorbidities is also reduced compared to those who choose dialysis.

    • Make sure to adjust doses of medications for renal failure and avoid drugs that have neurotoxic metabolites (morphine).

How to utilize team care?

  • Palliative care consultant

  • Hospice referral

  • Clergy

  • Geriatrics Consultant

  • Psychologists

  • Social workers

Are there clinical practice guidelines to inform decision making?

  • Renal Physician's Association's (RPA's) 2010 Clinical Practice Guideline Shared Decision Making: The Withholding and Withdrawal from Dialysis

  • Evidence is limited in this area with few randomized controlled trials (RCTs)

Other considerations

  • Patients who stop dialysis with little residual renal function die within 8 days.

  • Explore bereavement support for the patient’s family members and friends.

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