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:
SPIKESand 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 startto 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
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)
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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