Case 14: Diagnosis & Conclusions

Case 14 Index

Diagnosis: End Stage Kidney Disease (ESKD) with plan for conservative management and palliative care

Case Summary:  Here we have a difficult case of an elderly gentleman with progression of kidney disease with multiple significant comorbidities including heart failure and dementia. He also has poor functional status and is currently a nursing home resident. Advanced care planning is crucial for kidney disease patients and their families.

Observational data has shown that initiation of dialysis in nursing home patients with ESKD is associated with a significant decline in functional status. In fact, those with multiple co-morbidities may live just as long, if not longer, than those who initiate dialysis.

It is important to assure patients and their families that conservative management or non-dialytic therapy  is not withholding care – conservative management is an active treatment that requires a close relationship with the nephrologist for monitoring and symptom management.  Per the Renal Physicians Association (RPA) clinical practice guideline (click here for more from the RPA), a “time-limited trial of dialysis” may be appropriate for patients who have an uncertain prognosis, or for whom a consensus cannot be reached about providing dialysis.

Acknowledging and responding to emotion is an important part of difficult conversations, whether it is delivering bad news or discussing end of life care. The mnemonic NURSE below can help you through these types of conversations:

N
Naming
“It sounds like you are frustrated.”
Name the emotion you are seeing, and give the individual time to respond.
U
Understanding
“I understand this must be a difficult time.”
Express understanding without assuming you can know exactly what they are going through.
R
Respecting
“You are doing a wonderful job advocating for your father.”
Show respect for the caregiver or the patient for their hard work and perseverance.
S
Supporting
“I will be here throughout the process and do my best to support you.”
Align with your patient and their family and assure them you are on their team.
E
Exploring
“Tell me more about that.”
Take the opportunity to ask for more explanation of a feeling or emotion and be sure to listen.

Though shared decision making is critical for patients of all ages, those who are older than 65 years of age account for the largest proportion of the incident ESKD population. Physicians and care providers of these patients must understand the importance of these challenging conversations. As recently as 2015, surveyed nephrology fellows answered that training in this area was suboptimal and that they did not feel prepared to have end-of-life-care discussion.

The RPA provides an advanced care planning tool found here that physicians and providers can use to begin the shared decision making process. The clinical practice guideline on Shared Decision Making in the Appropriate Initiation and Withdrawal of Dialysis from the RPA may also be valuable.

For more, take a look here:

  1. Kurella Tamura M, Covinsky KE, Chertow GM, Yaffe K, Landefeld CS, McCulloch CE: Functional status of elderly adults before and after initiation of dialysis. N. Engl. J. Med. 361: 1539–1547, 2009
  2. Combs SA, Culp S, Matlock DD, Kutner JS, Holley JL, Moss AH: Update on end-of-life care training during nephrology fellowship: a cross-sectional national survey of fellows. Am. J. Kidney Dis. Off. J. Natl. Kidney Found. 65: 233–239, 2015
  3. Berns SH, Camargo M, Meier DE, Yuen JK: Goals of Care Ambulatory Resident Education: Training Residents in Advance Care Planning Conversations in the Outpatient Setting. J. Palliat. Med. 20: 1345–1351, 2017
  4. Chronic Kidney Disease and Progression, Nephrology Self-Assessment Program (NephSAP). American Society of Nephrology: 355-356, 2015

Case 14 Index
Case 14 Introduction
Case 14 Physical Exam
Case 14 Further Discussion
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