Dr Jamilla Hussain, Clinical Academic Fellow, Dr Andrew Mooney, Consultant Nephrologist, Leeds Teaching Hospitals Trust, and Dr Lynne Russon, Consultant in Palliative Medicine, Wheatfields Hospice, Sue Ryder Care and Leeds Teaching Hospitals Trust, UK, explain the background to their longer article that has been selected as ‘Editor’s choice’ in the October issue of Palliative Medicine
The number of patients referred to renal services has dramatically increased in recent years and many of the patients are elderly with multiple comorbidities.
Dialysis for end stage renal failure is a challenging treatment for many patients; it involves spending a large amount of time in hospital, significant morbidity and has a 20% annual mortality.
A service was set up in 2006 in a renal outpatient clinic where patients were given the choice of either dialysis or ‘conservative kidney management’. This involves looking after all other aspects of renal failure such as dietary advice, fluid balance, blood pressure and renal anaemia, but instead of dialysis it offers a greater emphasis on symptom control and social support as patients’ renal function deteriorates. The patients who opt into conservative treatment are managed by a multidisciplinary team consisting of a nephrologist, a palliative medicine consultant, a predialysis nurse and a social worker.
Our paper published in the October edition of Palliative Medicine, discusses the outcomes of patients who chose conservative kidney management and compares them to the group who chose dialysis. Once a choice of non-dialysis became a positive choice the numbers grew, from a handful of patients to 24% of a regional clinic. Integration within an existing clinic made the transition easier for patients and although there were some patients who changed from dialysis to conservative kidney management, there were very few who changed to dialysis.
For all over 70-year-olds, the group who chose dialysis lived approximately two years longer, but this survival advantage was lost for patients who were over 80 years old, had a high comorbidity score or a poor performance status. Performance status was found to be the most important predictor.
The group that chose dialysis, in addition to the time they spent receiving dialysis electively in hospital, were also much more likely to be admitted as an emergency and die in hospital. Approximately half of the additional survival time is likely to be spent in hospital.
Nationally in Britain, 69% of dialysis patients die in hospital, but in our study 47% of the conservatively managed patients died in hospital. Our study also found that 20% of patients who chose dialysis, died before they reached dialysis, and despite being a poor prognostic group, none of them were referred to palliative care services.
There has been significant mutual learning between the two specialities as a result of this joint clinic and it is possible that this non-interventional treatment approach, to a frail elderly population with multiple comorbidities, may be applicable to other long-term conditions.
To find out more…
This post relates to a longer article, ‘Comparison of survival analysis and palliative care involvement in patients aged over 70 years choosing conservative management or renal replacement therapy in advanced chronic kidney disease’ by Jamilla A Hussain, Andrew Mooney and Lynne Russon. Palliat Med October 2013 27: 829-839. First published on May 7, 2013 doi:10.1177/0269216313484380.
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