Supporting pathways to palliative care for people diagnosed with chronic kidney disease

Aims: To identify current practice of offering palliative care and compare with evidence-based best practice and determine associations between initiation of palliative care and predictors of uptake of conservative care.

Background: The increasing acceptance of elderly onto dialysis programs has heightened interest in and study of the process of end-of-life decision-making in ESKD, and the role of palliative care in the later stages of treatment. A chart review was conducted as part of a wider research program to describe current clinical practice.

Methods: A chart review of the 45 CKD and dialysis patients who died in 2006-2008 in North Tasmania aimed to determine the associations between patient or family request, or actual withdrawal of RRT and/or referral for palliative care, and recorded potential predictors of withdrawal in the last 12 months of life. Qualitative and quantitative analysis was performed.

Results: The presence of, advanced health care directives, patients wish to die, and stroke were associated with family request for withdrawal. The loss of will to live, behavioural changes, severe pain, loss of ADLs were associated with patient request for withdrawal. Who controls this process fluctuates from time to time. A limited range of language is used to express the recognition of the need to die.

Conclusion: Loss of function, particularly from stroke, and severe pain are interpreted as representing levels of suffering which would justify the need to withdraw. The influence of patient, family and clinicians on this decision involves negotiation and equivocation.