Incorporating Palliative Care Into Your Dialysis Unit

Incorporating Palliative Care Into Your Dialysis Unit

Alvin H. Moss, MDAlvin H. Moss, MD

West Virginia UniversityWest Virginia University

Alvin H. Moss, MDAlvin H. Moss, MD

West Virginia UniversityWest Virginia University

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RWJF ESRD Workgroup Recommendation:

Dialysis Units

RWJF ESRD Workgroup Recommendation:

Dialysis Units

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.

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.

ObjectivesObjectivesObjectivesObjectives

Describe the components of a Describe the components of a dialysis unit palliative care dialysis unit palliative care programprogram

Explain how each component can Explain how each component can be implementedbe implemented

Apply the elements of palliative Apply the elements of palliative care to a tragic ESRD patient care to a tragic ESRD patient casecase

Describe the components of a Describe the components of a dialysis unit palliative care dialysis unit palliative care programprogram

Explain how each component can Explain how each component can be implementedbe implemented

Apply the elements of palliative Apply the elements of palliative care to a tragic ESRD patient care to a tragic ESRD patient casecase

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“Not ready to go yet”“Not ready to go yet”

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.

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.

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“Not ready to go yet”“Not ready to go yet”

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.

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.

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“Not ready to go yet”“Not ready to go yet”

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.

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.

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“Not ready to go yet”“Not ready to go yet”

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.

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.

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“Not ready to go yet”“Not ready to go yet”

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 What is missing from the care of this patient?this patient?

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 What is missing from the care of this patient?this patient?

Components of a Renal Palliative Care ProgramComponents of a Renal Palliative Care Program

A Palliative Care FocusA Palliative Care Focus

-Educational activities (in-services)-Educational activities (in-services)

-QI activities (M & M conferences)-QI activities (M & M conferences)

-“Would you be surprised…?”-“Would you be surprised…?”

Pain & Sx Assessment & Management ProtocolsPain & Sx Assessment & Management Protocols

Systematized Advance Care PlanningSystematized Advance Care Planning

Psychosocial and Spiritual Support (peer Psychosocial and Spiritual Support (peer counselors)counselors)

Terminal Care Protocol (includes hospice)Terminal Care Protocol (includes hospice)

Bereavement Program (includes memorial service)Bereavement Program (includes memorial service)

A Palliative Care FocusA Palliative Care Focus

-Educational activities (in-services)-Educational activities (in-services)

-QI activities (M & M conferences)-QI activities (M & M conferences)

-“Would you be surprised…?”-“Would you be surprised…?”

Pain & Sx Assessment & Management ProtocolsPain & Sx Assessment & Management Protocols

Systematized Advance Care PlanningSystematized Advance Care Planning

Psychosocial and Spiritual Support (peer Psychosocial and Spiritual Support (peer counselors)counselors)

Terminal Care Protocol (includes hospice)Terminal Care Protocol (includes hospice)

Bereavement Program (includes memorial service)Bereavement Program (includes memorial service)

Pain and Symptom Assessmentand Management Protocols

Causes of Pain in Hemodialysis PatientsN=103/205*

Causes of Pain in Hemodialysis PatientsN=103/205*

CauseCause # Patients# Patients PercentPercent

MusculoskeletalMusculoskeletal 6565 6363

OsteoarthritisOsteoarthritis 2020 1919

MusculoskeletalMusculoskeletal 1919 1919

OsteoporosisOsteoporosis 1212 1212

RA, Bone Dis, OsteoRA, Bone Dis, Osteo 1414 1414

Related to dialysisRelated to dialysis 1414 1414

Periph NeuropathyPeriph Neuropathy 1313 1313

Periph Vasc DisPeriph Vasc Dis 1010 1010

Carpal tunnel synCarpal tunnel syn 22 22

OtherOther 1919 1919

Davison, AJKD 2003;42:1239-1247

* 19 patients had more than one type of pain.

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ESRD Patient Assessments of QOLESRD Patient Assessments of QOL

N=165N=165

Sites: DC, NY, WVSites: DC, NY, WV

Mean age: 60.9 yrsMean age: 60.9 yrs

Gender: 52% menGender: 52% men

Dialysis duration: 44 monthsDialysis duration: 44 months

Race: 33% African-AmericanRace: 33% African-American

Biochemical markers: Hb 11.8; Kt/V 1.6; Alb 3.7Biochemical markers: Hb 11.8; Kt/V 1.6; Alb 3.7

Diabetics: 34%Diabetics: 34%

Karnofsky Performance Score: 60%Karnofsky Performance Score: 60%

N=165N=165

Sites: DC, NY, WVSites: DC, NY, WV

Mean age: 60.9 yrsMean age: 60.9 yrs

Gender: 52% menGender: 52% men

Dialysis duration: 44 monthsDialysis duration: 44 months

Race: 33% African-AmericanRace: 33% African-American

Biochemical markers: Hb 11.8; Kt/V 1.6; Alb 3.7Biochemical markers: Hb 11.8; Kt/V 1.6; Alb 3.7

Diabetics: 34%Diabetics: 34%

Karnofsky Performance Score: 60%Karnofsky Performance Score: 60%

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ESRD Patient Assessment of QOLESRD Patient Assessment of QOL

Single item scale: Single item scale: Considering all parts of Considering all parts of my life—physical, emotional, social, spiritual, my life—physical, emotional, social, spiritual, and financial—over the past two days the and financial—over the past two days the quality of my life has beenquality of my life has been::

Very bad 0----------------------------10 ExcellentVery bad 0----------------------------10 Excellent

Single item scale: Single item scale: Considering all parts of Considering all parts of my life—physical, emotional, social, spiritual, my life—physical, emotional, social, spiritual, and financial—over the past two days the and financial—over the past two days the quality of my life has beenquality of my life has been::

Very bad 0----------------------------10 ExcellentVery bad 0----------------------------10 Excellent

Single Item Assessment of QOLSingle Item Assessment of QOL

Figure 1. Patient Rating of Overall Quality of Life

0

5

10

15

20

25

1 to 4 5 6 7 8 9 10

Single Item Scale

%

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ESRD Patient Assessment of QOLESRD Patient Assessment of QOL

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:_________________

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:_________________

The Importance of Pain As a SymptomThe Importance of Pain As a Symptom

Figure 2. Most Common Symptoms Reported by Symptomatic Patients

0

5

10

15

20

25

30

35

40

45

50

Pain Trouble w ith sleep Tiredness Shortness of breath

Symptoms

%w

ith

sym

pto

m

Types of Pain ReportedTypes of Pain Reported

Figure 3. Source of Pain in Patients Reporting Pain

0

5

10

15

20

25

30

35

40

Extremities Cramps Stomach Unspecif ied Chest Arthritis

Nature/Source of Pain

% o

f P

atie

nts

Association Between Reports Association Between Reports of Troublesome Symptoms of Troublesome Symptoms

and Quality of Life Measuresand Quality of Life Measures

Association Between Reports Association Between Reports of Troublesome Symptoms of Troublesome Symptoms

and Quality of Life Measuresand Quality of Life Measures

138

119

94.5

37.629 21.7

7.56.5 5.3

24.623.418.3

020406080

100120140160

MQOL TotalScore

MQOLPhysicalSubscale

QOL SingleItem Index

SWLS

no symptoms 1 symptom 2+ symptoms

138

119

94.5

37.629 21.7

7.56.5 5.3

24.623.418.3

020406080

100120140160

MQOL TotalScore

MQOLPhysicalSubscale

QOL SingleItem Index

SWLS

no symptoms 1 symptom 2+ symptoms

To t

al S

core

Tot

al S

c or e

Note: All results statistically significant, p values <.01Note: All results statistically significant, p values <.01

Pain Assessment Ask the patient and BELIEVE his/her complaintAsk the patient and BELIEVE his/her complaint

Use a systematic approach to assessment using a Use a systematic approach to assessment using a validated pain scalevalidated pain scale

Pain HistoryPain History

Physical examinationPhysical examination

Diagnostic ProceduresDiagnostic Procedures Reassess frequentlyReassess frequently

WHO 3-Step LadderWHO 3-Step Ladder

1 mild

2 moderate

3 severe

Morphine

Hydromorphone

Methadone

Levorphanol

Fentanyl

Oxycodone

± Adjuvants

A/Codeine

A/Hydrocodone

A/Oxycodone

A/Dihydrocodeine

Tramadol

± Adjuvants

ASA

Acetaminophen

NSAIDs

± Adjuvants

Nociceptive pain . . .Nociceptive pain . . .

Direct stimulation of intact nociceptorsDirect stimulation of intact nociceptors

Transmission along normal nervesTransmission along normal nerves

sharp, dull, aching, throbbingsharp, dull, aching, throbbing

somaticsomaticeasy to describe, localizeeasy to describe, localize

visceralvisceraldifficult to describe & localizedifficult to describe & localize

Tissue injury apparentTissue injury apparent

ManagementManagement

opioidsopioids

adjuvant / co-analgesicsadjuvant / co-analgesics

Direct stimulation of intact nociceptorsDirect stimulation of intact nociceptors

Transmission along normal nervesTransmission along normal nerves

sharp, dull, aching, throbbingsharp, dull, aching, throbbing

somaticsomaticeasy to describe, localizeeasy to describe, localize

visceralvisceraldifficult to describe & localizedifficult to describe & localize

Tissue injury apparentTissue injury apparent

ManagementManagement

opioidsopioids

adjuvant / co-analgesicsadjuvant / co-analgesics

Neuropathic pain . . .Neuropathic pain . . .

Disordered peripheral or central nervesDisordered peripheral or central nerves

Compression, transection, infiltration, ischemia, Compression, transection, infiltration, ischemia, metabolic injurymetabolic injury

Described as burning, tingling, shooting, stabbing, Described as burning, tingling, shooting, stabbing, electrical electrical

ManagementManagement

• opioidsopioids

• adjuvant / co-analgesics often requiredadjuvant / co-analgesics often required

Disordered peripheral or central nervesDisordered peripheral or central nerves

Compression, transection, infiltration, ischemia, Compression, transection, infiltration, ischemia, metabolic injurymetabolic injury

Described as burning, tingling, shooting, stabbing, Described as burning, tingling, shooting, stabbing, electrical electrical

ManagementManagement

• opioidsopioids

• adjuvant / co-analgesics often requiredadjuvant / co-analgesics often required

Opioids to Avoid in Kidney FailureOpioids to Avoid in Kidney Failure

meperidinemeperidine

morphinemorphine

propoxyphenepropoxyphene

meperidinemeperidine

morphinemorphine

propoxyphenepropoxyphene

Constipation . . .Constipation . . .

Common to all opioidsCommon to all opioids

Opioid effects on CNS, spinal cord, myenteric Opioid effects on CNS, spinal cord, myenteric plexus of gutplexus of gut

Easier to prevent than treatEasier to prevent than treat

Start stimulant laxative at the same time as opioidStart stimulant laxative at the same time as opioid

SennaSenna

CasanthranolCasanthranol

Common to all opioidsCommon to all opioids

Opioid effects on CNS, spinal cord, myenteric Opioid effects on CNS, spinal cord, myenteric plexus of gutplexus of gut

Easier to prevent than treatEasier to prevent than treat

Start stimulant laxative at the same time as opioidStart stimulant laxative at the same time as opioid

SennaSenna

CasanthranolCasanthranol

EPEC Module 4, 1999

Advance Care PlanningAdvance Care Planning

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RWJF ESRD Workgroup Recommendation:

Advance Care Planning

RWJF ESRD Workgroup Recommendation:

Advance Care Planning

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.

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.

Advance Care PlanningAdvance Care Planning

Identification of Medical Power of AttorneyIdentification of Medical Power of Attorney Goals of treatmentGoals of treatment Cardiopulmonary resuscitation (CPR)Cardiopulmonary resuscitation (CPR) Feeding tubesFeeding tubes Mechanical ventilationMechanical ventilation Dialysis Dialysis Organ and tissue donationOrgan and tissue donation

Identification of Medical Power of AttorneyIdentification of Medical Power of Attorney Goals of treatmentGoals of treatment Cardiopulmonary resuscitation (CPR)Cardiopulmonary resuscitation (CPR) Feeding tubesFeeding tubes Mechanical ventilationMechanical ventilation Dialysis Dialysis Organ and tissue donationOrgan and tissue donation

Focus on Health States, Focus on Health States, not Treatmentsnot Treatments

Focus on Health States, Focus on Health States, not Treatmentsnot Treatments

“ “ Under what conditions would you not want to Under what conditions would you not want to live?”live?”

““Is it more important to you to live as long as Is it more important to you to live as long as possible despite some suffering or to live for a possible despite some suffering or to live for a shorter time but without suffering?”shorter time but without suffering?”

“ “ Under what conditions would you not want to Under what conditions would you not want to live?”live?”

““Is it more important to you to live as long as Is it more important to you to live as long as possible despite some suffering or to live for a possible despite some suffering or to live for a shorter time but without suffering?”shorter time but without suffering?”

Dialysis Patients’ Preferencesfor End-of-Life Care (%)

Dialysis Patients’ Preferencesfor End-of-Life Care (%)

0

20

40

60

80

100

CurrentHealth

MildDementia

SevereDementia

PermComa

Tube Feeding

Mech Vent

CPR

Dialysis

0

20

40

60

80

100

CurrentHealth

MildDementia

SevereDementia

PermComa

Tube Feeding

Mech Vent

CPR

Dialysis

Singer.JASN 1995

Increasing the Completion of AD Increasing the Completion of AD by Chronic Dialysis Patientsby Chronic Dialysis Patients

Increasing the Completion of AD Increasing the Completion of AD by Chronic Dialysis Patientsby Chronic Dialysis Patients

focus on health states, not interventions focus on health states, not interventions (Singer, Holley)(Singer, Holley)

involve surrogates in discussions (Moss, involve surrogates in discussions (Moss, Singer, Holley, Swartz)Singer, Holley, Swartz)

increase dialysis unit staff’s attention to and increase dialysis unit staff’s attention to and comfort with discussing advance directives comfort with discussing advance directives (Perry, Holley)(Perry, Holley)

focus on health states, not interventions focus on health states, not interventions (Singer, Holley)(Singer, Holley)

involve surrogates in discussions (Moss, involve surrogates in discussions (Moss, Singer, Holley, Swartz)Singer, Holley, Swartz)

increase dialysis unit staff’s attention to and increase dialysis unit staff’s attention to and comfort with discussing advance directives comfort with discussing advance directives (Perry, Holley)(Perry, Holley)

DNR in the Dialysis Unit:A Form of Advance Directive

DNR in the Dialysis Unit:A Form of Advance Directive

Poor outcomes with CPR of dialysis patientsPoor outcomes with CPR of dialysis patients

Patients’ rights to self-determinationPatients’ rights to self-determination

Patients’ belief that other patients’ wishes for Patients’ belief that other patients’ wishes for DNR status should be honoredDNR status should be honored

Poor outcomes with CPR of dialysis patientsPoor outcomes with CPR of dialysis patients

Patients’ rights to self-determinationPatients’ rights to self-determination

Patients’ belief that other patients’ wishes for Patients’ belief that other patients’ wishes for DNR status should be honoredDNR status should be honored

Psychosocial and Spiritual SupportPsychosocial and Spiritual Support

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RWJF ESRD Workgroup RWJF ESRD Workgroup RecommendationRecommendation

RWJF ESRD Workgroup RWJF ESRD Workgroup RecommendationRecommendation

CMS should require dialysis units to provide CMS should require dialysis units to provide reasonable time for social workers to reasonable time for social workers to counsel patients on psychosocial issues counsel patients on psychosocial issues surrounding end-of-life care. At present, surrounding end-of-life care. At present, social workers are not using their social workers are not using their professional skills for psychosocial support professional skills for psychosocial support of patients because they are given other of patients because they are given other roles such as arranging patient roles such as arranging patient transportation. Others might perform these transportation. Others might perform these functions.functions.

CMS should require dialysis units to provide CMS should require dialysis units to provide reasonable time for social workers to reasonable time for social workers to counsel patients on psychosocial issues counsel patients on psychosocial issues surrounding end-of-life care. At present, surrounding end-of-life care. At present, social workers are not using their social workers are not using their professional skills for psychosocial support professional skills for psychosocial support of patients because they are given other of patients because they are given other roles such as arranging patient roles such as arranging patient transportation. Others might perform these transportation. Others might perform these functions.functions.

Peer Resource ConsultingPeer Resource Consulting

Role modelingRole modeling

Information Information dispensingdispensing

Empathic listeningEmpathic listening

Teaching how to Teaching how to work with the work with the health care systemhealth care system

Clarifying valuesClarifying values

Role modelingRole modeling

Information Information dispensingdispensing

Empathic listeningEmpathic listening

Teaching how to Teaching how to work with the work with the health care systemhealth care system

Clarifying valuesClarifying values

Helping problem Helping problem solvesolve

Relieving anxietyRelieving anxiety

Legitimizing feelingsLegitimizing feelings

Consumer identityConsumer identity

AdvocacyAdvocacy

Bridging staff and Bridging staff and patientspatients

Helping problem Helping problem solvesolve

Relieving anxietyRelieving anxiety

Legitimizing feelingsLegitimizing feelings

Consumer identityConsumer identity

AdvocacyAdvocacy

Bridging staff and Bridging staff and patientspatients

PRC TrainingPRC Training

Self Awareness Problem Solving

ValuesClarification

Sexuality

AssertivenessGrief and Loss

Empathy andListening

Role Plays

Self Awareness Problem Solving

ValuesClarification

Sexuality

AssertivenessGrief and Loss

Empathy andListening

Role Plays

Questions to Explore Spiritual IssuesQuestions to Explore Spiritual Issues

Is faith (religion, spirituality) important to you in Is faith (religion, spirituality) important to you in this illness?this illness?

Has faith (religion, spirituality) been important to Has faith (religion, spirituality) been important to you at other times in your life?you at other times in your life?

Do you have someone to talk to about religious Do you have someone to talk to about religious matters?matters?

Would you like to explore religious matters with Would you like to explore religious matters with someone?someone?

Is faith (religion, spirituality) important to you in Is faith (religion, spirituality) important to you in this illness?this illness?

Has faith (religion, spirituality) been important to Has faith (religion, spirituality) been important to you at other times in your life?you at other times in your life?

Do you have someone to talk to about religious Do you have someone to talk to about religious matters?matters?

Would you like to explore religious matters with Would you like to explore religious matters with someone?someone?

Lo B, Quill T, Tulsky J. Discussing palliative care with patients. Ann Intern Med 1999 May;130(9):744-9.

Questions Useful to Discuss Spiritual and Existential IssuesQuestions Useful to Discuss Spiritual and Existential Issues

What do you still want to accomplish during your What do you still want to accomplish during your life?life?

What might be left undone if you were to die What might be left undone if you were to die today?today?

What is your understanding about what happens What is your understanding about what happens after you die?after you die?

Given that your time is limited, what legacy do Given that your time is limited, what legacy do you want to leave your family?you want to leave your family?

What do you want your children and What do you want your children and grandchildren to remember about you?grandchildren to remember about you?

What do you still want to accomplish during your What do you still want to accomplish during your life?life?

What might be left undone if you were to die What might be left undone if you were to die today?today?

What is your understanding about what happens What is your understanding about what happens after you die?after you die?

Given that your time is limited, what legacy do Given that your time is limited, what legacy do you want to leave your family?you want to leave your family?

What do you want your children and What do you want your children and grandchildren to remember about you?grandchildren to remember about you?

Terminal Care ProtocolTerminal Care Protocol

Would you be surprised if the patient died in the next year?Would you be surprised if the patient died in the next year?

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Referral to Hospice or Use of a Palliative Care Approach

Referral to Hospice or Use of a Palliative Care Approach

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.”

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.”

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RWJF ESRD Workgroup Recommendation:

CMS and ESRD Networks

RWJF ESRD Workgroup Recommendation:

CMS and ESRD Networks

CMS should work in conjunction with CMS should work in conjunction with hospice and the ESRD Networks to hospice and the ESRD Networks to develop manuals and training for develop manuals and training for clinicians regarding coordination and clinicians regarding coordination and linkage of dialysis and hospice care for linkage of dialysis and hospice care for ESRD patients.ESRD patients.

CMS should work in conjunction with CMS should work in conjunction with hospice and the ESRD Networks to hospice and the ESRD Networks to develop manuals and training for develop manuals and training for clinicians regarding coordination and clinicians regarding coordination and linkage of dialysis and hospice care for linkage of dialysis and hospice care for ESRD patients.ESRD patients.

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RWJF ESRD Workgroup Recommendation:

CMS

RWJF ESRD Workgroup Recommendation:

CMS

CMS should allow application CMS should allow application of the Medicare hospice benefit of the Medicare hospice benefit to ESRD patients who are to ESRD patients who are certified by their physicians as certified by their physicians as terminally ill but choose to terminally ill but choose to continue dialysis until they die. continue dialysis until they die.

CMS should allow application CMS should allow application of the Medicare hospice benefit of the Medicare hospice benefit to ESRD patients who are to ESRD patients who are certified by their physicians as certified by their physicians as terminally ill but choose to terminally ill but choose to continue dialysis until they die. continue dialysis until they die.

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“Not ready to go yet”“Not ready to go yet”

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?What should have been done?

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?What should have been done?

Bereavement ProgramBereavement Program

Baystate Medical Center Dialysis Unit Memorial Service

Videotape (5 min)

Baystate Medical Center Dialysis Unit Memorial Service

Videotape (5 min)

ConclusionsConclusions Pain and symptom management are Pain and symptom management are

directly related to dialysis patient QOL.directly related to dialysis patient QOL.

Pain is the most troublesome symptom for Pain is the most troublesome symptom for dialysis patients.dialysis patients.

Advance care planning is necessary to Advance care planning is necessary to respect dialysis patients’ wishes, including respect dialysis patients’ wishes, including for CPR.for CPR.

Psychosocial and spiritual support are key Psychosocial and spiritual support are key components of ESRD patient care.components of ESRD patient care.

Pain and symptom management are Pain and symptom management are directly related to dialysis patient QOL.directly related to dialysis patient QOL.

Pain is the most troublesome symptom for Pain is the most troublesome symptom for dialysis patients.dialysis patients.

Advance care planning is necessary to Advance care planning is necessary to respect dialysis patients’ wishes, including respect dialysis patients’ wishes, including for CPR.for CPR.

Psychosocial and spiritual support are key Psychosocial and spiritual support are key components of ESRD patient care.components of ESRD patient care.

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Take-Home MessageTake-Home Message

The necessary components to The necessary components to incorporate palliative care into incorporate palliative care into dialysis units are known. What dialysis units are known. What is required on the part of each is required on the part of each dialysis unit is a commitment to dialysis unit is a commitment to make it happen.make it happen.

The necessary components to The necessary components to incorporate palliative care into incorporate palliative care into dialysis units are known. What dialysis units are known. What is required on the part of each is required on the part of each dialysis unit is a commitment to dialysis unit is a commitment to make it happen.make it happen.