Incorporating Palliative Care Into Your Dialysis Unit. Alvin H. Moss, MD West Virginia University. RWJF ESRD Workgroup Recommendation: Dialysis Units.
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Alvin H. Moss, MD
West Virginia University
Dialysis units should institute palliative care programs that include pain and symptom management, advance care planning, and psychosocial and spiritual support for patients and families.
A 73 year old woman developed end-stage renal failure from multiple myeloma. She has had the multiple myeloma for six years and received numerous courses of chemotherapy. Her oncologist said that her marrow was now “burned out” and that further chemotherapy would not be of benefit. The patient had been chronically ill and had been admitted monthly for infections, anemia, and bleeding. She was anemic with a Hb of 7 and thrombocytopenic with a platelet count of 90,000.
Because she had a terminal condition, her attending physician did not think that dialysis should be offered to the patient. The patient, however, stated that she was “not ready to go yet” and that she wanted dialysis.
The patient was started on CAPD and lived for nine months. During this time, she had 13 hospital admissions for anemia, upper and lower GI bleeding, and CHF, and she was transfused with 46 units of packed RBCs and 190 units of platelets.
On the day she died, she experienced a cardiac arrest at her daughter’s home. The rescue squad was called, and the patient underwent unsuccessful CPR for one hour. She was declared dead in the hospital emergency room.
Sadly, she was no more ready to go after nine months of dialysis then she had been prior to the start of dialysis.
What is missing from the care of this patient?
and Management Protocols
Sites: DC, NY, WV
Mean age: 60.9 yrs
Gender: 52% men
Dialysis duration: 44 months
Race: 33% African-American
Biochemical markers: Hb 11.8; Kt/V 1.6; Alb 3.7
Karnofsky Performance Score: 60%
Single item scale: Considering all parts of my life—physical, emotional, social, spiritual, and financial—over the past two days the quality of my life has been:
Very bad 0----------------------------10 Excellent
Please list the PHYSICAL SYMPTOMS or PROBLEMS which have been the biggest problem for you over the past two days.
Over the past two days, one troublesome symptom has been:_________________
Note: All results statistically significant, p values <.01
EPEC Module 4, 1999
Nephrologists should routinely invite patients to express their end-of-life care preferences in the required semi-annual short-term and annual long-term care planning meetings.
CMS should require dialysis units to provide reasonable time for social workers to counsel patients on psychosocial issues surrounding end-of-life care. At present, social workers are not using their professional skills for psychosocial support of patients because they are given other roles such as arranging patient transportation. Others might perform these functions.
Lo B, Quill T, Tulsky J. Discussing palliative care with patients.
Ann Intern Med 1999 May;130(9):744-9.
Recommendation No. 9, RPA/ASN CPG
“…With the patient’s consent, persons with expertise in such care, such as hospice health care professionals, should be involved in managing the medical, psychosocial, and spiritual aspects of end-of-life care for these patients. Patients should be offered the option of dying where they prefer including at home with hospice care. Bereavement support should be offered to patients’ families.”
CMS should work in conjunction with hospice and the ESRD Networks to develop manuals and training for clinicians regarding coordination and linkage of dialysis and hospice care for ESRD patients.
CMS should allow application of the Medicare hospice benefit to ESRD patients who are certified by their physicians as terminally ill but choose to continue dialysis until they die.
A 73 year old woman developed end-stage renal failure from multiple myeloma. She has had the multiple myeloma for six years and received numerous courses of chemotherapy. Her oncologist said that her marrow was now “burned out” and that further chemotherapy would not be of benefit.
What should have been done?
The necessary components to incorporate palliative care into dialysis units are known. What is required on the part of each dialysis unit is a commitment to make it happen.